SUPPLEMENTAL QUALIFICATIONS STATEMENT RECORD OF AERONAUTICAL EXPERIENCE Complete and Submit this Form with Your Personal Qualifications Statement (Form 1170/21 -- Form Approved: OMB No. 50-R0481) (You may provide this information in other written format. If all of the relevant information is not provided with your application or resume, however, you could lose consideration for a job.) ======================================================================= 1. NAME: ________________________________________________ 2. DATE OF BIRTH: ______________ 3. SOCIAL SECURITY NUMBER: _______-____-________ 4. AIRMAN CERTIFICATES HELD TYPE DATE ISSUED CERTIFICATE NUMBER A. Airline Transport Pilot ___________ __________________ B. Commercial Pilot ___________ __________________ C. Private Pilot ___________ __________________ D. Flight Instructor ___________ __________________ E. Mechanic 1. Airframe ___________ __________________ 2. Powerplant ___________ __________________ F. Flight Engineer 1. Turbo Jet ___________ __________________ 2. Recip ___________ __________________ 3. Turbo Prop ___________ __________________ G. Medical ___________Class: First Second Third 5. RATING RECORD Indicate certificate privileges for ratings below by showing appropriate letter in column 1. A = Airline Transport B = Commercial C = Private Show "D" for Flight Instructor Rating in column 2, where appropriate. 1 2 ___ ___ Airplane Single Engine Land ___ ___ Airplane Single Engine Sea ___ ___ Airplane Multiengine Land ___ ___ Airplane Multiengine Sea ___ ___ Instrument Airplane ___ ___ Instrument Helicopter ___ ___ Glider ___ ___ Helicopter ___ ___ Gyroplane ___ Other Ratings (Specify) ________________________ ___ Type Ratings (Specify) ________________________ 6. CLASSIFICATION OF FLYING HOURS Total Hours Total Hours-to-Date Type and Total Hours Last 12 Months Pilot-in-Cmd Co-Pilot A. Total Pilot Time ________ _______ _______ B. Single Engine ________ _______ _______ C. Twin Engine ________ _______ _______ D. Four Engine ________ _______ _______ E. Multiengine Less than ________ _______ _______ 12,500lbs. Gross Weight F. Multiengine More than ________ _______ _______ 12,500 lbs. Gross Weight G. Jet ________ _______ _______ H. Actual Instrument ________ _______ _______ I. Hood Instrument ________ _______ _______ K. Synthetic Trainer ________ _______ _______ L. Rotorcraft ________ _______ _______ M. Night ________ _______ _______ N. Primary Instructor ________ _______ _______ O. Advanced Instructor ________ _______ _______ P. Instrument Instructor ________ _______ _______ Q. Multiengine Instructor ________ _______ _______ R. Scheduled Air Carrier ________ _______ _______ S. Military Scheduled ________ _______ _______ T. Other Military ________ _______ _______ U. Executive Transport ________ _______ _______ V. Total Hours Last 12 months ________ _______ _______ W. Total Hours Last 6 years ________ _______ _______ 7. FLIGHT TIME BY AIRCRAFT Weight Class Under Over Total Hours-to-Date Airplane Make & Model 12,500 12,500 Plt-in-Cmd Co-Plt Flt Eng. _____________________ ____ ____ _______ _______ _______ _____________________ ____ ____ _______ _______ _______ _____________________ ____ ____ _______ _______ _______ _____________________ ____ ____ _______ _______ _______ _____________________ ____ ____ _______ _______ _______ _____________________ ____ ____ _______ _______ _______ _____________________ ____ ____ _______ _______ _______ _____________________ ____ ____ _______ _______ _______