COMMUNITY-COMPASSION-COMMITMENT Volunteer Pilots Pilot information form We’re glad you’re here. If you have a MINIMUM of 300 hours as Pilot in Command and want to help us with our mission, please complete the form below and Jeff will contact you. Personal InformationName(Required) First Middle Initial Last Aircraft Registration Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneBusiness PhoneCellularFax NumberEmail(Required) Other Means of Contact Sex Marital Status Date of Birth MM slash DD slash YYYY Spouse/Partner's Name First Last Contact In Case of EmergencyEmergency Contact Name(Required) First Last Relationship(Required) Emergency Contact Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency Contact Phone(Required)Additional Data Angel Flight Should Be Aware Of:Aviation InformationLicense Held:Certificate #(Required) Certificate Date of Issue(Required) MM slash DD slash YYYY Private Private Certificate Date of Issue MM slash DD slash YYYY Commercial Commercial Certificate Date of Issue MM slash DD slash YYYY ATP ATP Date of Issue MM slash DD slash YYYY IFR IFR Date of Issue MM slash DD slash YYYY Night Rating Night Rating Date of Issue MM slash DD slash YYYY Class of Medical Held(Required) Expiry Date of Medical(Required) MM slash DD slash YYYY Restrictions on Medical Has your license or medical certificate ever been revoked or suspended?(Required) Yes No Please explain why your certificate was revoked or suspended.Log Book Information Day Hours(Required)Night Hours(Required)Multi HoursIFR Hours - AirIFR Hours - SimTotal HoursHours in Last 12 Months(Required)Hours in Last 3 Months(Required)Hours in Last 28 Days(Required)Aircraft Information Aircraft Owned/Available for Angel Flight Angel Flight Considerations Insurance Details Insurance Expiry Date MM slash DD slash YYYY Amount of Coverage Number of SeatsHome Airport Mission Availability(Required)When are you normally available for missions and how much notice do you required?Signature(Required)Form signature will be dated automatically when you submit this form.