Form FS-5700-20 Airplane Pilot Record

FS-5700-0020 (03/2019)
OMB 0596-0015 (Omission of Exp. Date approved by OMB)

INSTRUCTIONS FOR AIRPLANE PILOT QUALIFICATIONS AND APPROVAL RECORD
Note: Print legibly in ink.
SECTION I – Pilot Information (to completed by applicant pilot)
Blocks 1 through 4 – Self-explanatory
Block 5 – Enter Current Employer
Blocks 6 through 8 – Self-explanatory
Blocks 9 and 13 – Include employers for whom worked, whose flight environment qualifies pilot for the type of flying to be
contracted.
Block 10 through 12 – Self-explanatory.
Block 14 through 16 – Self-explanatory.
Block 17 – If medical certificate expires during the contract period, prepare and send a copy of the new one to the inspector
pilot.
Block 18 – Self-explanatory.
Block 19 – Enter contracted aircraft and total PIC hours in that make/model of aircraft.
Blocks 20 through 29 – Self-explanatory
Block 30 – Mountainous Terrain Flight-Flight conducted above terrain referenced in 14 CFR 95.11. In addition, mountainous
terrain flight must be at or below 2500 feet AGL. The pilot must be able to verify flight meeting the requirements outlined in this
definition.
Blocks 31 through 34 – Self-explanatory
Blocks 35 through 38 – Under the VFR, IFR, and IFR W/AP columns check (√) each that apply to the FAA Form 8410-3 for that
check ride.
Blocks 39, 40, and 42 – OAS (Office of Aviation Services), Department of Interior and USFS (United States Forest Service),
Department of Agriculture
Block 43 through 46 – Self-explanatory
Section II - Self-explanatory.

FS-5700-0020 (03/2019)
OMB 0596-0015 (Omission of Exp. Date approved by OMB)

BURDEN AND NONDISCRIMINATION STATEMENTS
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0596-0015. Response to this collection of information is mandatory (5 USC 552a). The time
required to complete this information collection is estimated to average 25 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color,
national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual
orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any
public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at
202-720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington,
DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at
(800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider,employer and lender.
PRIVACY ACT NOTICE
Collection and use of the information on this form covered under Privacy Act System of Records USDA/FS-44 (Pilot
Qualification Records) and consistent with the provisions of 5 USC 552a (Privacy Act of 1974).
Purpose and Use: This information, along with data you may have supplied previously and information developed by
investigation will be available to Federal employees for the following uses:
1. To determine your pilot qualifications to comply with contract specifications.
2. Transfer to the U.S. Department of Justice in the event of litigation.
3. Transfer, in the event there is indicated violationo r potential violation of a statute, regulation, whether civil, criminal, or
regulatory in nature, to the appropriate agency or agenices, whether Federal, state, local, or foreign, charged with the
responsibility of investigation or prosecuting such violation or charged with enforcing or implementing the statute, rule,
regulation, order or license violated or potentially violated.

FS-5700-0020 (03/2019)
OMB 0596-0015 (Omission of Exp. Date approved by OMB)

AIRPLANE PILOT QUALIFICATIONS AND APPROVAL RECORD
(Reference FSH 5709.16)

► S E C T I O N

I

–

1. Name (Last, First, Middle Initial)

P I L O T

I N F O R M A T I O N

2. Date of Birth

( F i l l

i n

t h e

b l a n k s )

3. Telephone No.

◄

4. Home Address (Street, City, State & Zip Code)
5. Employed by

6. Address

7. Telephone No.

8. Employed since

9. Previous Employer

10. Address

11. Telephone No.

12. Period Employed

13. Previous Employer

14. Address

15. Telephone No.

16. Period Employed

17. Medical Certificate

18. Airman Certificate (Check all that apply)

19. Aircraft To Be flown
(a)

a. Class _______________________
b. Date _______________________

Flight Type

a. Number _________________________________
b. ATP

c. Com

d. Instrument

e. SEL

f. MEL

g. SES

h. MES

i. CFI

Hours

j. Type Ratings

______________________________

35.

21. Pilot-in-Command (PIC) Airplane

36.

22. Total X-Country

37.

23. Total Night

38.

24. Instrument: In Flight

Total PIC Hours

1. ______________

_______________

2. ______________

_______________

3. ______________

_______________

FAA FLIGHT CHECKS
Make/Model A/C

Date

20. Total Pilot Time (Airplane)

(b)

VFR

IFR

IFR W/AP

Note: FAA Flight Checks Must Cover Type of Operations Required By Contract.

25. Instrument: Actual

39. Date of Previous Agency Card Approval
a.

26. Instrument: Simulated
27. PIC Airplane: Last 12 Months

OAS_________

40. Date of Last Agency Flight Check

b. USFS _________

a.

OAS_________

41. Aircraft Accidents/FAA Violations Filed Within Last 5 Years:
Date and Explanation)

28. PIC Airplane: Last 60 Days

No

42. Previous OAS or USFS Approval Denied, Suspended, or
Revoked: (If yes, Attach Date and Explanation)

29. PIC “Low Level” Opns (-500 AGL)

b. USFS_________

Yes (If yes, Attach

No

Yes

30. PIC “Mountainous Terrain”
31. PIC Aircraft over 12,500 # Gr. Wt.

43. PIC “Air Tactical” Operations: Number of Missions in the Last 24 Months: ______________
44. Airtanker Operations Only:
a. Date Last PIC IFR Check in Type ___________ b. Date Last FAR 61.55 SIC Check
_________________
c. No. of Takeoff/Landings Last 90 Days ________ d. No. of Night Takeoff/Landings Last 90 Days _______

32. PIC Airtanker/Dispensing Operations
33. PIC, Single Engine Airplane

34. PIC, Multi-Engine Airplane

► S E C T I O N

I I

–

Land
Sea
Land

I certify that the information listed on this form is true and correct. In addition, I certify that I have read the
statements on the back of this form covering information pursuant to Public Law 93-579 (Privacy Act of 1974) and
any amendment thereto.

Sea

45. Signature (Pilot)

F o r

I n s p e c t o r s

1. Missions Approved For: (Inspector shall initial)
Recon
Ski Operations

U s e

46. Date

O n l y

( I n i t i a l

a p p r o p r i a t e

M i s s i o n s )

Airtanker Pilot (AKC/AKP/AKI/AKTP)

Leadplane

Mountainous Terrain

Remote Water Operations

Air Tactical

Airtanker (PIC/SIC)

Point to Point

Low Level

Back Country Airstrip

Sketch Mapping

Smokejumper (PIC/SIC)

Limitations

Unprepared Landing Site

Infrared Operations

Seat Pilot Level (1/2)

Other

Paracargo

Other

◄

2. SEL _________ 3. SES ________ 4. MEL _________ 5. MES ___________ 6. IFR, W/SIC __________ 7. IFR, Single Pilot __________ 8. Single Engine IFR _________
9. Type Aircraft Approved For:
10. Print Name (Inspector)
15. Aircraft/Contract Rental Agreement No(s).

11. Signature (Inspector)

12. Agency

13. Issue Date

14. Expiration Date

FS-5700-0020 (03/2019)
OMB 0596-0015 (Omission of Exp. Date approved by OMB)
16. Remarks (Limit 7,000 charecters)