Name (First, Middle initial, Last): _____________________________________________ Date: _____________

Street and Post Office Box (if P. O. Box used): _____________________________________________________

City: _______________________ State: _____________ Zip: _________ Day Phone: _____________________

Night Phone: _____________ Beeper: ______________ Fax: _________________ E-mail: _________________

Social Security No: _________________ Birthdate: ________________ Business Name: ___________________

General Pilot Information:

Ratings: ASEL: ____ Multi: ____ Comm’l ____ CFI ____ CFH ____ ATP ____ Other: __________________

Flying Time: Total Hours _________ Total Years: ________ Breakdown of Flight Hours: VFR: _____ IFR: ____

Multi: ____ Other: ______ As of (Date): _____________ Pilot Certificate No: ___________________________

Drivers License No./State: _________________ Medical Expires: __________________ Class 1___ 2___ 3 ____

BFR expires: ________________ Base Airport: _____________________ Identifier: _____ FBO: ____________

___________ Airport Address: ______________________________________ Telephone: ___________________

Aircraft Information:

Aircraft 1: Single__ Twin___ Piston ___ TurboProp ___ IFR Cert ___ Pressurized ___ Known Ice ___ Seats ____

Own: ___ Rent ___ Make _______ Model ______ Model No. _____ Call Sign N______ Based at FBO above ___

Aircraft 2: Single ___ Twin ___ Piston ___ TurboProp ___ IFR Cert ___ Pressurized ___ Known Ice ___ Seats __

Own ____ Rent ____ Make ______ Model _____ Model No. _____ Call Sign N ______ Based at FBO above ___

I AM __ AM NOT ___ USUALLY AVAILABLE DURING NORMAL BUSINESS HOURS

I AM __ AM NOT ___ USUALLY AVAILABLE DURING EVENING HOURS

I AM __ AM NOT ___ USUALLY AVAILABLE DURING WEEKENDS

ANNUAL CONTRIBUTION: $35.00 Used to defray the costs of operating the Flight Division of Wings for Children. This contribution is tax deductible. Please include with your completed application, copies of pilot certificate(s), medical and insurance form.

INSURANCE: All Wings for Children flights require that the aircraft be insured at the expense of the owner/renter. The policy should have standard coverage and the premium should not increase. Please add Wings for Children, Flight Division as additional insured. We simply require tha tyou be covered. Send a photocopy of the front page of your policy in order to complete your application.

I, the undersigned applicate hereby affirm that all information I have provided is accurate and correct, and that I agree to abide by all applicable Federal Aviation Regulations.

Applicants Signature: ____________________________________________________

Date: _______________________