Form Gui - Class-A Assistant Guide Or Assistant Guide Biennial License Renewal - Department Of Commerce, Community, And Economic Development Of Alaska Page 3
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1
2
3
4
5Have you:
YES
NO
14. been or are you currently addicted to, excessively used, or misused alcohol, narcotics, barbiturates or
other habit forming drugs?
15. been or are you currently being treated for bipolar disorder, schizophrenia, paranoia, a psychotic
disorder, substance abuse, depression (except situational or reactive depression) or any other
mental or emotional illness?
16. had or do you have a physical disability or physical illness which may impair or interfere with
your ability to provide big game commercial services?
A “Yes” answer may not prejudice your application, failure to report honestly may.
If you answered “yes” to questions 1 - 13, you MUST submit a full explanation of the circumstances of the event(s) in
your own words on a separate piece of paper. Also, you MUST submit any/all supporting documents that are
applicable (court records including charging documents, judgments, certificate of completion, board actions,
investigation notices, etc.).
If you answered “yes” to questions 14 – 16 you MUST also submit documentation from your health care provider
stating their relationship to the issue of concern and attesting to your ability to provide guide-outfitter, guiding or
transporter services.
TRANSPORTATION
YES
NO
1. Did you personally pilot an aircraft and/or watercraft to transport clients in 2012?
2. Did you personally pilot an aircraft and/or watercraft to transport clients in 2013?
3. Will you personally pilot an aircraft to transport clients in 2014 and/or 2015?
4. If “yes” to question 17, 18, and/or 19, do you have at least 500 hours of flying time in Alaska or a valid
commercial pilot’s license?
FAA Air Carrier Certificate # (Part 135):
5. Do you plan to operate a motorized vessel in Navigable Waters?
If “yes”, U.S. Coast Guard Operator’s License #:
Expiration Date:
WARNING: The board may deny, suspend, or revoke the license of a person who has obtained or attempted to
obtain a license to practice as a Class-A Assistant Guide by fraud or deceit. The person may also be subject to
criminal charges for unsworn falsification. (AS 11.56.210).
I certify that the information in this application is true and correct.
SIGN HERE
Applicant's Signature
Date: ___________________________________________
08-4209 (Rev. 11/06/13)
Page 3
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