Student & Renter Information

Full Name*

Mailing Address*

City*

State*

Zip Code*

Phone*

Emergency Contact Name and Phone*

Email Address*

Birthday*

01/01/2020 Format

Height*

Weight*

Used for aircraft weight and balance

License You Hold*

None

Student

Private

Commercial

CFI

CFII

ATP

Ratings/Endorstments You Currently Hold*

None

Instrument

Multi-Engine

Tail Wheel

High Performance

Complex

Number of Hours*

Number of Hours in Cessna 172:

If you are a student pilot or working on a license or rating, have you taken your written?*

Yes No N/A

Date of Written if Taken

01/01/2020 Format

Written Score if Taken

Do you have a current medical?*

Yes No

Type of Medical

Third Class

Second Class

First Class

Basic Med

Date of Medical

01/01/2020 Format

Are you a U.S. Citizen?*

Yes No

TSA requires certain documents such as birth certificate, photo ID, and/or passport to be on file if you are taking flight lessons. International students require additional immigration documentation and requirements are more stringent. We will contact you with a list of required documents.

Comments

Please tell us a little about yourself and what you are interested in learning.

How did you hear about us?

STATEMENTS OF RENTAL APPLICANT
I represent that as of the date of this application:
1. IF REQUIRED (does NOT apply to students), I have an effective Pilot Certificate and Medical Certificate (if a Medical Certificate is required for the Pilot Certificate privileges being exercised) and satisfy the FAA’s flight review requirements.
2. Within the greater of the past 36 months or 100 flight hours, I have not:
a) had an aircraft accident, incident or insurance claim;
b) had my pilot or driver’s license surrendered, suspended or revoked; or, been arrested for, or charged with, operating an aircraft or motor vehicle under the influence of drugs or alcohol;
c) been convicted of, pleaded guilty or no contest to, any felony or misdemeanor other than parking violations.
3. No Insurer has, within the past 36 months, canceled or refused to renew an aircraft insurance policy for me.
4. I understand this application is to add me as a pilot on an aircraft insurance policy.
5. I understand that I can obtain aircraft “Renter’s Insurance” in addition to the current insurance policy held by my Moses Aviation Services.
6. The information I have supplied on this application is true and correct and no material information has been withheld.
7. I understand the Company may accept or reject this application. I will be mailed a written notice of rejection.

Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for insurance or statement of claim containing any false or misleading information or any fact material thereto, commits a fraudulent insurance act, which is a crime.

I AGREE with the above statements

I DO NOT agree with the above statements

AIRCRAFT DAMAGE POLICY
If an incident or accident occurs and it is due to pilot error (not mechanical), the PIC is responsible for replacement cost if the aircraft is totaled, or the cost to repair the damages, or the insurance deductible, whichever is less.
We ONLY carry full-coverage insurance on N738CX and N3817Q. A current renter’s insurance policy is required to rent any other Moses Aviation Services aircraft, and is strongly recommended when renting ANY of our planes. Avemco, AOPA, and many other independent aviation insurance agents offer non-owner policies.

I AGREE with the above statements

I DO NOT agree with the above statements

Signature*