Today's Date:

Member Name:

Phone Number:

 

License Type: Private___ Commercial___ ATR___

Additional Training: Night___ Mountain___ IFR___

Total Hours:______ Total PIC Hours:________

PIC Hours in the last 60 days: ______

PIC Hours in the Last 1 year: ______

Last Date Flown: ______________

 

A/C Type Required: ______________

A/C Ident Preferred:______________

Proposed date of departure:_________________ Time:__________

Proposed date of return: _________________ Time:__________

Total Flight Hours Estimate on route: ___________________

Proposed Routing (give as much detail as possible:

 

 

Survival Kit needed: Yes___ No____

Life Jackets needed: Yes____ No____

Do you plan on landing at any airports that are not blacktop or cement? Yes___ No___   If yes, give the airport name (s):

 

Name of Passengers:

Person to Contact in event of an emergency: Name:_____________________________ Phone#____________________________________

 

OFFICE USE ONLY:

Request approved: Yes____ No____  Date:_____________________________

By:______________________

Comments: