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Date 
Name                                 (Attach Photo If Possible) 
Address

Telephone Number 
Membership Number                Age 
Marital Status 
Number of Dependents 
Education 

AIR LINE EXPERIENCE                                Date
Hours     First Reserve Copilot     Company      From     To     Type of Aircraft 



MILITARY EXPERIENCE
Hours     First Copilot     Branch     Type of Aircraft 


TOTAL                    For Hdqs. Use only 
(Air Line Hours)
(Military Hours)
(Other Hours)
GRAND TOTAL

COMMERICAL RATINGS
Is your Department of Commerce License still in force?
Class and Number     Date Issued
Do you hold an Instrument Rating?
Do you hold an Air Transport Rating?
When Issued      Is it active?
Do you hold a Seaplane Rating?     Class
Last Air Line Employed by
Date of Release 
Position Held 
Cause of Release