Pilot and Aircraft Info

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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.  

Current members, to  update information only fill out the Pilot Update form.

Print and mail completed form with your membership application

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:  check one     PRIVATE     COMMERCIAL  ATP

Ratings:  check all that apply.     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  _________

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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

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