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64a Interagency Form
Seaplane
PIC Make & Model
PIC Make & Model
PIC Make & Model
IFR Simulated
IFR Actual
PIC Night
PIC Large Airplane (>12,500#)
PIC Turboprop
PIC Jet
PIC Low Level Airplane (<500’ AGL)
PIC Airtanker/Dispensing Ops.
PIC Mission Specific
PIC Typical Terrain
Hours
h.
Date of Last Agency Flight Evaluation
Date of Previous Agency Card
□YES □NO
□YES □NO
□YES □NO
PILOT HISTORY:
__________________
__________________
(Attach a copy)
□OAS □USFS
□OAS □USFS
Aircraft accidents within the last 5...
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