Safety & Loss Prevention

Pilot Questionaire

University of Wisconsin
Pilot Questionaire
Current Certificates and Ratings
(Check/Circle all which apply)

Private____

 Airplane____
Commercial____

Helicopter____
ATP____ Single- engine (circle one): Land/Sea____
Instrument Rating____ Multi-engine (circle one): Land/Sea____
CFIA____ Restricted to Center Line Thrust____
CFII____ Type Ratings (specify)____
CFIMEI____ Mechanic: Aircraft/Powerplant/IA____
CFI - Other (specify)____
 
 
If you have less than 400 hours PIC, state # of PIC hours after private certificate awarded:_______

Medical: Class, Date and Physical Waivers:___________________________

Please indicate the following information for BFR, completed Wings phase, or flight checkride (required every 12 months). Pilot approval will expire on the anniversary date unless/until notification is provided to Risk Management.

Type: (circle) BFR/Wings Phase #____/Checkride Date:________ Where given:____
By whom:________________ Aircraft Flown:____________ Time Logged:_______

Safety Seminars (6 hours required every 12 months). Please advise Risk Management as courses are taken during the year.
 
 


Date:_______ Provider:___________ Location:____________ # of Hours:_______
Date:_______ Provider:___________ Location:____________ # of Hours:_______
Date:_______ Provider:___________ Location:____________ # of Hours:_______
Date:_______ Provider:___________ Location:____________ # of Hours:_______

Current Pilot Expeience as of _________________: Total PIC time, all aircraft_______
(All time will be considered logged time,
unless otherwise noted.) 		Total time, instrument_______
Total time, night_______
Total time, high performance_______


List each aircraft for which you wish to be certified to fly on University business:
Make
Model
HP
Total Seats
Ownership Code*
Total PIC in each
PIC last 12 mos. in each
Logged Hrs
# of flts
Avg/Pass/Flts
 
 
 


I certify that the information above is true and correct. I agree to provide a copy of my medical certificate or copies of logbook entries upon request. I understand that in order to fly on University business, I must meet the requirements of the FAR 61.57: Recent Flight Experience: Pilot-in-Command; and comply with UW Operational & Flight rules.
Signature:___________________________________
Date:___________________________________
*ownership codes:
O = owned or co-owned, P = partnership, C = club-owned, R = rented