MedFlight Indiana - Pilot Registration

Please complete and submit the following Pilot Registration form. Confirmation will be sent via email when your application and supporting documentation have been received. This confirmation will also include instructions for registering for an available mission and orientation session.

In addition to the online information, we will also require

A copy of your pilot license, medical and insurance.
Copies of your log book (or other document) indicating
a current bi-annual review.
A copy of your drivers license

You may fax these items to our office or mail to info on Contact Us page.

NOTE: The minimum requirements for a pilot are 250 logged hours, an Instrument rating and attendance at an orientation meeting within 60 days of application. See Pilot FAQ page for further information.

*First Name:

*Last Name:

Organization:

*Address:

*City:

*State:

*Zip Code:

Country:

*Phone Number:

Cell Number:

Fax Number:

*E-mail:

Certificate Number(s):

Medical Class:

Examination Date:

Date of Last BFR:

Certificates & Ratings Held:

Flight Hours Total:

Flight Hours Single Engine:

Flight Hours Multi-Engine:

Flight Hours Instrument:

Flight Hours Night:

Airport I Mainly Fly From:

Airport State ID:

Aircraft Make:

Aircraft Model:

Aircraft N-Number:

Aircraft Engine:

Single Twin

Aircraft Cruise Speed:

Seats

Aircraft Colors:

Aircraft Special Equipment:

Verification Code

* Please Enter Code