FS-5700-20a Helicopter Pilot Record

FS-5700-20A Instructions
PRIVACY ACT NOTICE
General - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals supplying information for
inclusion in a system of records.
Authority - The authority to collect the information on the attached form is contained in 5 USC 552A.
Purpose and Use - This information, along with data you may have supplied previously, and information developed by investigation will be for use by
such as:
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 violation or potential violation of a statute, regulation, whether civil, criminal, or regulatory in nature, to the
appropriate agency or agencies, 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.
I. Applicant Information
a. Pilot Name (Last, First) – Self-explanatory.
b. Office Telephone - Self-explanatory.
c. E-mail – Company or email address used for business.
d. Employer – The Company that holds the contract.
e. Previous Employer – Only required if a pilot card was issued to the pilot while employed.
f. PIC HELICOPTER – Provide Pilot-in-Command time as required by the contract. Additional documentation of flight time may be required.
Ldgs=Number of landings.
g. PILOT HISTORY – Self-explanatory.
h. 14 CFR 135 QUALIFICATIONS - Self-explanatory.
i. OTHER FAA 14 CFR DOCUMENTATION – Provide dates completed for FAA required training and/or evaluations. Be prepared to present
documentation to an OAS pilot inspector as required.
j. M M & Series – Make, Model & Series. VTR – Vertical Reference flight time, flight time acquired while maneuvering this MM&S helicopter via
vertical reference. Mtn – Mountainous terrain flight time acquired in this MM&S at and below 1000 feet within designated mountainous areas defined
by 14 CFR 95 Subpart B, 12 mo – Flight time in this MM&S within the previous 12 calendar months, Hours – PIC time in this MM&S. It may be
necessary to provide additional MM&S within a make and model family to document required make and model time.
k. Applicant Remarks – Add anything you feel is pertinent.
l. Self-explanatory – Electronic signatures are acceptable.
m.
Company Official must be Director of Operations, Chief Pilot or equivalent. First box must always be checked. The second box is only
required when applicant is vertical reference longline approved or seeking evaluation. Electronic signatures are acceptable.
II. Inspector Information:
a. Checklist of Documents Verified by the Inspector – A checked box indicates that you, the inspector, looked at the required documents and then
returned them to the applicant. Provide expiration date as required.
b. Check if applicant is approved and attach a copy of the OAS-30B/5700-3A issued to the applicant.
c. Check if applicant is not approved and add any required comments in the remarks section.
d. Electronic signatures are acceptable
e. Add any comments necessary.

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 the 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 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, S.W., Washington, DC 20250-9410, or call
toll free at (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 and employer.
The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 522) govern the confidentiality to be provided for information
received by the Forest Service.

FS-5700-20A
OMB 0596-0021 Exp 12/2021

U.S. Forest Service

INTERAGENCY HELICOPTER PILOT
EVALUATION APPLICATION
I. Applicant Information
b. Office Telephone

a. Pilot Name (Last, First)

c. E-mail

d. Employer

e. Previous Employer

Address

Dates Employed

City, ST ZIP

Previous Employer

Telephone

Dates Employed

to

Telephone

to

Telephone

Hire Date

PIC HELICOPTER

Hours

Total

g. PILOT HISTORY
Date of Last Agency Flight Evaluation _________________

☐ OAS ☐ USFS

Last 12 Months

Date of Previous Agency Card

☐ OAS ☐ USFS

f.

_________________
(Attach a copy)

Last 90 Days

☐YES
☐YES
☐YES

More than 12,500 lbs.
Turbine Engine

☐NO Aircraft accidents within the last 5 years.
☐NO FAA violations within the last 5 years.
☐NO OAS or USFS pilot card denied, suspended, or revoked.
(Attach details and explanation for each YES)

Reciprocating Engine
Mountainous Terrain

h.

Date

NVG Operations

14 CFR 135 QUALIFICATIONS

Make, Model & Series

Type of Qualification

Night Unaided

___________ _________________

☐VFR

☐IFR

☐IFR W/AP

☐SIC Only

Offshore Navigation

___________ _________________

☐VFR

☐IFR

☐IFR W/AP

☐SIC Only

Platform Ldgs

___________ _________________

☐ VFR

☐ IFR

☐IFR W/AP

☐SIC Only

___________ _________________

☐VFR

☐IFR

☐IFR W/AP

☐SIC Only

Vessel Ldgs

NA

Vertical Reference

(Attach FAA 8410-3 or equivalent)

IFR Simulated
IFR Actual
j.M

i.

M & Series

VTR

Mtn

12 mo

Hours

OTHER FAA 14 CFR DOCUMENTATION (dates as required)

61.55 SIC Qualification ____________

61.56 Flight Review

_____________

61.57 IFR Currency

____________

61.58 PIC Proficiency

_____________

133 Demonstration

____________

137 Demonstration

_____________

(Attach a copy of endorsements, letters or logbook entries when requested)
k. Applicant

Remarks

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

Pilot: __________________________________________________________________________
(Signature)

(Date)

m. ☐I certify that I have verified the information listed on this form and that it is true and correct to the best of my knowledge.

☐I certify that this pilot received a minimum of 10 hours of vertical reference/external load flight training for initial qualification, has received 2 hours of vertical reference longline
training within the past 12 calendar months, and has demonstrated proficiency in accordance the Interagency Helicopter Practical Test Standards.

Company Official: ________________________________________________________________________________________________________
(Print Name and Title)

(Signature)

II. Inspector Information:
a. Checklist of Documents Verified by the Inspector
☐Pilot Certificate
☐Medical Certificate
☐14 CFR 135 Evaluation
☐14 CFR 137 Endorsement
☐14 CFR 133 Endorsement
b.☐
d. Inspector:

Exp Date
☐VTR Training Endorsement
☐Signature Page – Ops & Safety Proc Guide
☐OAS-60B
☐OAS-64C
☐MTN_FLY

Approved attach OAS-30B/5700-3A

c.☐Disapproved

☐A110
☐GCNP-SFRA
☐MH1
☐MH2
☐MH3

(see remarks)

____________________________________________________________________________________________________________
(Print Name)

e. Remarks:

(Date)

(Agency)

(Date)

(Signature)

____________________________________________________________________________________________________________

______________________________________________________________________________________________________________________