Us Forest Service - Helicopter Pilot Qualifications And Approval Record
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1OAS-64B (12/12)
Contract Number:
USFS:
HELICOPTER PILOT QUALIFICATIONS AND APPROVAL RECORD
DOI:
SECTION I - Pilot Information (to be filled out by pilot seeking approval)
1. Name (Last, First, Middle Initial)
2. Date of Birth
3. Primary Telephone Number
4. Home Address (Street, City, State & ZIP Code)
5. E-Mail Address
6. Employed By
7. Address
8. Telephone No.
9. Employed Since (m/yr)
10. Previous Employer
11. Address
12. Telephone No.
13. Period Employed (m/yr)
to
14. Previous Employer
15. Address
16. Telephone No.
17. Period Employed (m/yr)
to
19. Most Recent Interagency Pilot Card: (attach copy)
18. Medical Certificate: (attach copy)
Class
Date
Limitations:
Date Issued:
Expiration:
Insp. Name:
Agency:
20. Airman Certificate: (attach copy)
Commercial
ATP
CFI
21. Most Recent Interagency Flight Evaluation Information
Number:
Other Ratings:
Date Evaluation Conducted:
Insp. Name:
Agency:
22. Aircraft accidents / FAA violations within the last 5 years:
23. Has a previous Interagency Pilot Card been denied, suspended or revoked?
Yes
No
No
Yes
(if Yes, explain in box 45)
(If Yes, please explain in box 45 or attach an additional sheet.)
(a)
(b)
(c) PIC Hours for Column "a" A/C
Helicopter Pilot-in-Command
PIC
Make, Model & Series
Flight Time & Type of Flight
Are you Type Rated for
Hours
Aircraft
Vertical
Mountain
Preceding
seeking approval in
column "a" aircraft?
Total
Reference
Flying
12 Months
Only
24. Total Helicopter
34.
Yes
No
N/A
25. T
Less than 12,500 lb
35.
Yes
No
N/A
Weight
Class
12,500 lb or more
36.
Yes
No
N/A
26. Turbine Engine
37.
Yes
No
N/A
38. Signature Page - Operations & Safety Procedures Guide
27. Reciprocating Engine
(Fire Only)
Attach Original
Not Applicable
28. Preceding 12 months
39. FAR 135 Evaluation: (FAA 8710-3 or Equivalent)
Attach Copy
Not Applicable
40. Equipment Check Endorsement:
Attach Copy
Not Applicable
29. Preceding 90 days
30. Mountain Flying
41. CFR 14 Part 61.56 Flight Review:
Attach Copy
Not Applicable
42. FAR 133 Endorsement :
Attach Copy
Not Applicable
31. NVG Operations
32. Offshore
43. FAR 137 Endorsement :
Attach Copy
Not Applicable
44. VTR Training Endorsement: (attach copy)
Snorkel
Longline
Not Applicable
33. Vertical Reference, VTR
OAS-60B
OAS-64C
OAS-89
45. Applicant Remarks:
46.
Attach Copy
Not Applicable
I certify that the information listed on this form is true and correct. In addition, I certify that I have read the statements
attached to this form covering information pursuant to Public Law 93-579 (Privacy Act of 1974)
47. Pilot Signature
48. Date
SECTION II - Special Use Mission Approval (to be filled out by Pilot Inspectors only)
3. Flight Evaluation
3. Flight Evaluation
1. Approved
4. Expiration
1. Approved
4. Expiration
2. Mission
2. Mission
Administered
Not
Administered
Not
(Initial)
Date (m/yr)
(Initial)
Date (m/yr)
Date (m/yr)
Administered
Date (m/yr)
Administered
Low Level (Recon. & Surv.)
"Trainee Only" Pilot
2
Helitack/Passenger Transport
Short Haul
External Load (belly hook)
Float Operations (fixed)
1
Water/Retardant Delivery
Platform Landings: Offshore
1
1
Longline VTR (150 ft)
Vessel Landings
1
2
Snorkel
VTR
Mirror
Night Vision Goggle Operations
1
ACETA Net Gun (all ACETA)
Mountainous Terrain Flight
1
Aerial Ignition: PSD
ACETA Eradication (only)
1
ACETA
Aerial Ignition: Torch
Gathering/Capture
(Herding)
2
1
Rappel Operations
ACETA Darting (only)
1
Cargo Letdown
Other
Snow Operations (deep snow)
Other
Designated "Pilot Trainer"
Other
1
2
Recurrence Flight Evaluation:
3 years
1 year
5. Make/Model/Series Aircraft:
6. Pilot Inspector (Print)
7. Pilot Inspector Signature
8. Agency
9. Issue Date
10. Card Expiration Date
a. ______________
c. ______________
b. ______________
d. ______________
11. Make, model, and series:
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