Pilot Questionnaire

University of Wisconsin
Pilot Questionnaire

Current Certificates and Ratings
(Check/Circle all which apply)

Private	________	Airplane	________
Commercial	________	Helicopter	________
ATP	________	Single-engine(circle one): Land / Sea	________
Instrument Rating	________	Multi-engine(circle one): Land / Sea	________
CFIA	________	Restricted to Center Line Thrust	________
CFII	________	Type Ratings (specify)	________
CFIMEI	________	Mechanic: Aircraft / Powerplant / IA	________
CFI - Other (specify)	___________________

If you have less than 400 hours PIC, state # of PIC hours after private certificate awarded:______

Medical: Class, Date and Physical Waivers:__________________________________________

Please indicate the following information for BFR, completed Wings phase, or flight checkride (required every 12 months). Pilot approval will expire on the anniversary date unless/until notification is provided to Risk Management.

Type: (circle) BFR / Wings Phase #_____ / Checkride Date:_________Where given:__________

By whom: __________________Aircraft Flown:__________________Time Logged:_________

Safety Seminars (6 hours required every 12 months) Please advise Risk Management, as courses are taken during the year.

Date:	________	Provider:	______________	Location:	______________	# of Hours:	_____
Date:	________	Provider:	______________	Location:	______________	# of Hours:	_____
Date:	________	Provider:	______________	Location:	______________	# of Hours:	_____
Date:	________	Provider:	______________	Location:	______________	# of Hours:	_____

Current Pilot Experience as of ____________________: (All time will be considered logged time, unless otherwise noted.)	Total PIC time, all aircraft_________
	Total time, instrument____________
	Total time, night________________
	Total time, high performance______

List each aircraft for which you wish to be certified to fly on University business:

Make	Model	HP	Total Seats	Ownership Code *	Total PIC in each	PIC last 12 mos. in each
Make	Model	HP	Total Seats	Ownership Code *	Total PIC in each	Logged Hrs	# of flts	Avg/Pass/Flts
______	______	______	_______	_________	________	__________	______	__________
______	______	______	_______	_________	________	__________	______	__________
______	______	______	_______	_________	________	__________	______	__________
______	______	______	_______	_________	________	__________	______	__________
(*ownership codes: O = owned or co-owned, P = partnership, C = club-owned, R = rented)

I certify that the information above is true and correct. I agree to provide a copy of my medical certificate or copies of logbook entries upon request. I understand that in order to fly on University business, I must meet the requirements of FAR 61.57: Recent Flight Experience: Pilot-in-Command; comply with all provisions of FAR 91: general operating and flight rules; and comply with UW Operational & Flight Rules.

Signature: ________________________________________________Date:___________

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