Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is your address registered with the FAA?
*
If not, do it immediately
Occupation
*
Date of Birth
*
MM
DD
YYYY
Weight (lb)
*
Email Address
*
Home Phone
*
(###)
###
####
Work Phone
(###)
###
####
Mobile Phone
(###)
###
####
Next of Kin
*
First Name
Last Name
Address of Next of Kin
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Driver's License No. & State
*
Airman's Certificate No.
*
SSA Member No.
*
Medical Class & Expiration
Glider certification or ratings held
*
Powered aircraft certification or ratings held
First glider flight
*
MM
DD
YYYY
Last biennial flight review date
*
MM
DD
YYYY
Last biennial flight review location
*
SSA, FAI, or other achievements, including date
Single-engine PIC hours
Multi-engine PIC hours
Launch Type Qualifications
Special training (cross-country camp, wave camp, etc.)
Have you had an accident while PIC?
*
Have you ever been cited for violation of FAA or Military Aviation Regulations?
*
Are you flying subject to any limitations, waivers, or restrictions?
*
Have you ever had an application for aircraft insurance declined?
*
Detailed explanations
Date, location, make & model of aircraft, and cause
Aircraft flown, number of flights, and PIC hours in the past 5 years and 90 days
I've flown at the following sites
I have CFI-G signoffs in my logbook for the following
By checking "Agree," I certify that I will fly only those BASA aircraft for which I have a CFI-G signoff and flight committee approval
*
By checking "Agree" and submitting this application, I certify that all information provided by me on this application is true and verifiable by independent documentation or the FAA.
*
