1. Personal
Information:
Name _____________________________________________
Home Address ______________________________________
___________________________________________________
Home Phone ________________________________________
Spouse's Name ______________________________________
Employer's Name _____________________________________
Business Address ____________________________________
___________________________________________________
Name, Address, & Phone # of Person to Contact in an Emergency:
___________________________________________________
___________________________________________________
___________________________________________________
State Driver's License #_______________________________
Date of Birth ________________________________________
Social Security # ____________________________________
2. Flight Experience (Hours unless otherwise stated):
Total Time P-I-C
Total Time P-I-C Last 90 Days
Breakdown:
Make/Model ________ /_______ Day Hours __________ Night Hours _____________
Make/Model ________ /_______ Day Hours __________ Night Hours _____________
Make/Model ________ /_______ Day Hours __________ Night Hours _____________
Make/Model ________ /_______ Day Hours __________ Night Hours _____________
Number of Takeoffs and Landings:
Day ______________________ Night _________________________________
Instrument Flight Experience:
P-I-C Last 6 Months ____________________________________________
Actual ________________________________________________________
Simulated _____________________________________________________
Number of Approaches ___________________________________________
As Pilot-In-Command or as Co-Pilot have you:
Had, or been involved in, any aircraft accidents? Yes____ No____
Had any violations of Federal Air Regulations? Yes____ No____
(If yes, please explain on separate page and attach to this form)
EXHIBIT C, Page 1 of 2
3. Airman Information:
Airman Certificate Number____________________________________________
Ratings and Limitations ____________________________________________
Medical Certificate Number ____________________________________________
Limitations ____________________________________________
Class ____________________________________________
Date of Expiration ____________________________________________
Biennial Flight Review:
Date of Expiration ____________________________________________
4. Renter's Insurance:
Name of Insurance Carrier ____________________________________________
Policy Number ____________________________________________
Limits of Liability ____________________________________________
Date of Expiration ____________________________________________
5. Aircraft Pilot Qualification:
Check
Pilot
Date |
Make |
Model |
Initials |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
_____________ |
VFR |
IFR |
Day |
Night |
_____________ |
_____________ |
_____________ |
_____________ |
6. Renter Hereby Represents and Warrants That:
A. I am a certificated pilot under the laws of the United States of America
and am rated and qualified for the flight in the Aircraft I desire to
rent.
B. I have a valid and current medical certificate. I have passed a Biennial
Flight Review within the last 24 calendar months.
C. I warrant that the information contained on this data card is correct.
D. I understand that the Operator is relying on this information to rent
the Aircraft only to me.
E. I understand that false information might invalidate insurance policies
rendering me personally liable for loss or damage resulting from an accident.
RENTER SIGNATURE:
____________________________________________
DATE: ____________________________________________