Application Form | Salem Pilot's Association

Apply

Name*

Address*

Your email*

Message*

ODL*

Occupation*

Employer*

Business Address

Work Phone

FAA Medical Certificate held*

Total Hours Logged*

Last 12 Months*

Ratings*

Date of last Flight Review*

FAA Violations or Accidents/Incidents last 5 Years?*

Yes

During the past 5 years, have you been convicted or entered diversion for any motor vehicle violations including driving under the influence of alcohol or a drug or had your driver’s license suspended or revoked?*

Yes

During the past 5 years, have you been involved as a driver in any motor vehicle accident?*

Yes

No or zero

Reference 1*

Reference 2*

Reference 3*

Remarks/Explanations

Consent*

By Checking the box. I authorize Salem Pilots Association to check references, driving records and other sources of information available tothem. I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge. If accepted as a member, I agree to abide by all rules of Salem Pilots Association and to be bound by the Association’s By-laws and Flight Rules.

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