Tandem Instructor Re-Certification Form printable pdf download

Tandem Instructor Re-Certification Form

Name __________________________________________________________________ Age

_______________

Mailing Address ________________________________________________________________________________

$35.00 U.S.

______________________________________________________________________________________________

City ______________________________

State ____________

Zip _______________

Country ___________________________________

Home Phone ___________________________

Work Phone ___________________________

Fax _________________________________

E-Mail ___________________________

Home Drop Zone ___________________________________________________________________



(Check here if Address Information has changed)

Total Number of Jumps ______________

Vector / Sigma Tandem Jumps ______________

Vector Sigma / Tandem Jumps In Last Year ______________

Instructional Rating(s) ( Please attach a copy ) _______________________________________________

USPA D-License / Equivalent ( Please attach a copy ) _____________________

USPA Membership # __________________________________

FAA Medical Certificate # ( Please attach copy ) _______________________________________________________________________________

How many Tandem Vector / Sigma’s do you own? ______________

I certify that all statements in this application are correct to the best of my knowledge.

X __________________________________________________

__________________________________________________

Signature

Date

Log of Recurrent Training Jumps ( if necessary )

Date

Aircraft

Name of Passenger

Examiner’s Comments and Signature

Endorsing Signature

Above renewal requirements verified by ( please print ): ______________________________________________________________________________

X _______________________________________________________________________________

______________________________________

Date

Endorsing offical must be a uninsured United Parachute Technologies, LLC

Tandem Vector / Sigma Instructor Examiner or Tandem Vector / Sigma System Owner

Form-267 Rev. 3 - 7/16/2015

1:1

Tandem Instructor Re-Certification Form