FlyingSamaritans

Los Amigos Chapter

 

Welcome to the Flying Samaritans Los Amigos Chapter Pilot Information page.  Before you complete this form you will want to read the Los Amigos Chapter Pilot Guidelines.  In addition, before participating on a Flying Samaritan's clinic trip you will be required to be a current member of the Flying Samaritans and have a signed Pilot Acknowledgement form.

This form  should be completed and submitted at the time a pilot member joins or renews membership. 

 

PILOT INFORMATION

Name:  (Last)   (First)      

Nickname by which you wish to be called: (example:  Jim,  Sam, Dottie)  

Pilot's Certificate Number:      Date of Issue:  (Mo/Yr)

Certificate Type:  PRIVATE     COMMERCIAL  ATP

Ratings:    SEL     MEL   INSTRUMENT     FLIGHT INSTRUCTOR     OTHER 

Total Hours PIC     PIC Last 12 Months    

Total PIC Hours in Aircraft listed below:   Make & Model Last 12 Months 

~~~

Your mailing address:    City   State    Zip

Contact telephone numbers (please include area code) :  Day Evening  

                  Cell                              E-Mail Address:

AIRCRAFT INFORMATION

Provide information on the aircraft you would most likely fly with the Sams.

 

A/C Make    A/C  Model    Year Built    Registration Number   N

 

A/C Colors:  Primary    Trim

 

 

Fuel Capacity  :  Gallons    Flight Time  Hours/Minutes

 

Airspeed    kts  mph         Gross Wt  lbs      Empty  Wt   lbs

 

Not counting yourself, how much total passenger weight will you carry in your aircraft:  lbs

 

Available Seats for Passengers  (Do not include pilots seat)

 

Aircraft Owner:   Aircraft is based at:

 

 

 I acknowledge that I have read the Los Amigos Chapter's Pilot Guidelines and agree to abide by the Guidelines.       I have also signed and submitted a Pilot Acknowledgement form, which is required by the International Board of Directors, before participating on a Flying Samaritans trip or other flying activity as Pilot in Command.    

Date:      I agree     I do not agree

 

The Los Amigos Chapter Pilot Coordinator, Don Downey,  will review your information  and will contact you.   If you have question, please contact Don at C310dd@aol.com

 

 

Thank you

Please press the "Submit" button to forward this information.