PILOT PROFICIENCY AWARD PROGRAM "WINGS"

APPLICATION

Certified Flight Instructor Information

All information must be included to process this application (Please Print Legibly or Type)

 

 

NAME_____________________________________________________________________________ ADDRESS___________________________________CITY _________________________________ STATE_________ZIP_______________TELEPHONE ______________ Fax Number____________ CERTIFICATE#________________ GRADE OF PILOT CERTIFICATE_____________________

 

 

 

Eligible For Phase: I II III IV V VI VII VIII IX X XI XII XIII XIV  XV XVI XVII XVIII XIX XX (Circle One)

 

If applying for Wings IV awards or above, please include a copy of your previous award.

Record of Recurrent Training

Safety Program Attended: _(Title)_______________________________________________________

Location _____________________________________________________ Date: _________________

 

Name& Signature of SPM, ASPM or ASC) _______________________________________________

 

 

 

Flight Training With Wings Pilot

 

 

As Per Advisory Circular AC 61-91H (Paragraphs 8a & 8b)

 

 

........................Date.......................... Pilot Name ............................Pilot Cert. #.........

 

Pilot #1 ______________ ____________________________ ___________________

 

 

Pilot #2 ______________ ____________________________ ___________________

 

 

Pilot #3 ______________ ____________________________ ___________________

 

 

For Phase IV and higher, complete the following:

 

DPE/ASI (circle one)________________________________________________________

 

Print Name and Sign

 

 

Date of Flight: __________________

 

 

Revised 08/01