Pilot Application - Arizona Department Of Administration
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6JANET NAPOLITANO
WILLIAM BELL
GOVERNOR
DIRECTOR
ARIZONA DEPARTMENT OF ADMINISTRATION
RISK MANAGEMENT SECTION
th
100 North 15
AVENUE, SUITE #301
Phoenix, Arizona 85007-2635
Telephone: (602) 542 1445; Facsimile: (602) 542 1800
PILOT APPLICATION (COMPLETE ENTIRE FORM)
PILOT HISTORY
PILOT NAME:
DAYTIME PHONE: #
ADDRESS:
DATE OF BIRTH:
DRIVER’S LICENSE #/STATE:
AIRMAN’S CERT.: #
MED. CLASS & EXP. DATE:
ARE YOU A STATE EMPLOYEE?
AGENCY:
HOW OFTEN DO YOU FLY ON STATE
PURPOSE OF FLYING ON STATE BUSINESS?
BUSINESS? ANNUAL FLIGHTS:
ANNUAL HOURS:
OCCUPATION:
If the answer to any of the following questions is yes, please give detail on
YES
NO
separate sheet.
Have you ever had any aircraft accidents?
Have you ever been cited for violations of civil/military aviation regulations?
Are you flying subject to limitations or a waiver?
Has your driver’s license ever been suspended or revoked?
Have you been arrested for operating a vehicle while under the influence of alcohol or
drugs?
Have you had any automobile accidents within the last five years?
CERTIFICATES / RATINGS
Indicate all certificates you currently hold:
Student
Airline (ATR)
Single Engine Land
Private
Instructor
Multi Engine Land
Commercial
Instrument Rating
Helicopter
List all aircraft type ratings you currently hold:
List all Manufacturer’s Ground and Flight Schools and dates you have attended for each aircraft make
and model:
Indicate date of your last biennial flight review and list if it was VFR or IFR:
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