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4
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Name
Phone Number
Email
Permanent Resident


Address Line 1
Address Line 2
Suburb
State
Postcode
Date of Birth
Height (cm)

Weight (kg)

Annual Salary
$
Gender

What types of aircraft do you fly?


Licence Number

What make/models of aircraft do you regularly fly?

Are you a member of a pilot union/association?

Have you ever had your licence suspended or cancelled?


Have you ever been convicted of a breach of Air Navigation Safety Regulation?


Have you been involved in an aircraft accident in the last 5 years?

Please estimate the number of hours flying in the next 12 months associated with the following activities:

Do you intend on engaging in pylon racing?

Do you intend on engaging in record attempts or speed trials?

Do you intend on engaging in any form of flying involving abnormal hazards?

Do you intend on engaging in fish spotting?

Do you fly outside Australia?

Do you intend on engaging in experimenting with or testing new parts, devices, design or aircraft types, or ultralight aircraft?