PRODUCER:

LANCE TOLAND ASSOCIATES

ADDRESS:

100 MIDFIELD DRIVE, GRIFFIN, GA 30224

PHONE:

770.227.5500

FAX:

770.227.8779

APPLICANT

ADDRESS

PILOTS NAME

PILOTS ADDRESS

OCCUPATION

EMPLOYER

HOW LONG

Driver’s License No.

Airman Certificate No.

Date & Class of last Medical

Bi-Annual Flight Review Date

CERTIFICATES AND RATINGS

Student

Single Engine Land

Aircraft Type Rating

Private

Multi Engine Land

Commercial

Single Engine Sea

Instrument

Helicopter

Mechanic Rating:

ATP

Other

Aircraft

CFI

Power Plant

TOTAL LOGGED CIVILIAN PILOT HOURS:

Pilot in Command:

Co-Pilot

TOTAL LOGGED MILITARY PILOT HOURS:

Pilot in Command:

Co-Pilot

Initial pilot training obtained from?

Where?

Complete Breakdown of Logged Pilot In Command Hours (Civilian & Military Combined)

HOURS

Single Engine Fixed Gear

Cross Country

Last 90 Days

Single Engine Retractable Gear

Night Flying

Last 12 Months

Multi-Engine under 12,500 lbs.

Instrument Flying

a. Actual Inst.

Multi-Engine over 12,500 lbs.

Single Engine Sea

b. Simulator

Turboprop

Turbojet

Helicopter Turbine

Helicopter Piston

Make & Model Aircraft for which approval is sought:

Total Logged Pilot In Command Hours in this Aircraft:

Date of last recurrent training in the make and model?

Where attended?

Are you flying under a waiver?

If YES, explain

Has your FAA or DOT license ever been suspended or revoked?

If YES, explain

10.

Have you ever had an Accident, Incident or Violation?

If YES, explain

11.

Have you ever had an application for Aircraft Hull or Liability Insurance declined by an Insurance Company?

If YES, explain

12.

Have you ever been convicted of or plead guilty to a charge of reckless driving or driving under the influence of alcohol or

drugs?

If YES, explain

IF ADDITIONAL SPACE IS NEEDED TO FULLY ANSWER ABOVE QUESTIONS, USE THE BACK OF THIS PAGE.

I CERTIFY THAT THE STATEMENTS IN THIS FORM ARE TRUE AND THAT NO MATERIAL INFORMATION HAS BEEN WITHHELD OR SUPPRESSED.

DATE

PILOT’S SIGNATURE