University of Wisconsin
Pilot History Data

Name:_________________________________Department:___________________________

Campus Address: _______________________ City _______________ Zip Code:__________

Home Address: _________________________ City _______________ Zip Code:__________

Home Phone:_________________Campus Phone:________________Fax:_______________

Birthdate:_______________ Pilot Certificate#:_____________

Electronic mail address : ____________________________________________________

State date & location where your pilot certificate was awarded.

Since obtaining your first pilot certificate, state date and aircraft flown for the following:

Formal Flight School Refresher(s):__________________________________

Flight Transition(s):_____________________________________________

Additional Rating(s):_____________________________________________

List manufacturer's ground and flight school(s) attended, if any:

1. Have you ever had an application for aircraft hull or liability insurance declined by an insurance company of underwriter? Yes_____________ No______________

2. While acting as pilot-in-command, have you:
- had or been involved in any FAA-defined accidents, in the air or while taxiing? Yes____________ No____________
- been cited for any violations of Federal Air Regulations? Yes____________No____________

3. Have you ever been convicted of operating a vehicle under the influence or alcohol or drugs?
Yes_____________ No______________

4. Has your driver's license been suspended during the past 5 years? Yes_______No________

If you have answered "Yes" to any of the above questions, please provide dates and explanation below or on reverse side.

I certify that the information above is true and correct.

Signature:_______________________________ Date: ______________
Reviewed - no change needed: Signature:_______________________________ Date: ______________
Reviewed - no change needed: Signature:_______________________________ Date: ______________

PilotApDoc 1/07