Safety & Loss Prevention

Pilot History Data

University of Wisconsin
Pilot History Data


Name:___________________________________ Department:_________________________________
Campus Address:_________________________ City:______________ Zip Code:___________
Home Address:___________________________ City:______________ Zip Code:___________
Home Phone: _______________ Campus Phone: ______________ Fax: _________________
Birthdate: ____________________ Soc.Sec.#: ________________
Pilot Certificate#: ______________
Email address: ______________________________________________________________

State date & location where your pilot certificate was awarded. _________________________________

Since obatining your first pilot certificate, state, date and aircraft flown for the following:

Formal Flight School Refresher(s):___________________________________
Flight Transitions:_______________________________________________
Additional Rating(s):_____________________________________________

List manufacturer's ground and flight school(s) attended, if any:


  1. Have you ever had an application for aircraft hull or liability insurance declined by an insurance company of underwriter?
    ____Yes ____No

  2. While acting as a pilot-in-command, have you:
    • had or been involved in any FAA-defined accidents, in the air or while taxiing?
      ____Yes ____No

    • been cited for any violations of Federal Air Regulations?
      ____Yes ____No

  3. Have you ever been convicted of operating a vehicle under the influence of alcohol or drugs?
    ____Yes ____No

  4. Has your driver's license been suspended during the past 5 years?
    ____Yes ____No


If you have answered "Yes" to any of the above questions, please provide dates and explanations below or on reverse side.


I certify that the information above is true and correct.

Signature:__________________________________ Date:_____________________________
Reviewed - no change needed: Signature:__________________________________ Date:____________________________
Reviewed - no change needed: Signature:__________________________________ Date:____________________________