Pilot Name

Time Out

Will Return By

Date

Tail Number N

Destination/Purpose

(Weather: 816-329-2850)

Information

Wind

Visibility

Sky Condition

Temp-DP

ALT

Runway

X-Wind Component

XC Take-Off Distance

XC Landing Distance

Notams

Aircraft Status

100 HR Due

Current Tach

HRS Remaining

Est. Time This Fit

Est. Hours Remaining

Current Hobbs

Oil Change Due

Annual Due

Transponder Due

ELT Due

Next AD Due: Date

Next AD Due: Hours

Documentation on Board?

Airworthiness

Registration

Pilot Operating Limitations

Weight & Balance

Are You a Student Pilot?
Yes
No

(If yes, this form must be signed by a flight instructor prior to dispatch)
**ATD airplanes are not authorized to operate on grass or gravel runways
without permission from ATD management.

Pilot Signature [Insert Full Name]

Instructor Signature [Insert Full Name]

I have been checked out in this make and model of aircraft by an ATD authorized Airman?
Yes
No

I have flown this make and model of aircraft in the past 90 days?
Yes
No

My Flight Review and FAA Medical are current?
Yes
No

If No to any of the above, this flight is not authorized without an ATD Approved CFI or Approval by ATD Management Please contact an ATD Instructor to bring your currency up to date.

Please Initial the following:

I understand that I may NOT operate this aircraft on a gravel runway.

I understand that I may NOT operate this aircraft on a grass runway unless it is a dual instruction flight by an ATD APPROVED INSTRUCTOR or an endorsement has been placed in my logbook by an ATD check airman authorizing each individual request.

I understand that the minimum charge for rental of an ATD Aircraft is .3 Hobbs hours per 1 hour scheduled (or in my possession, whichever is greater) during normal business hours of 8AM - 6PM. Please contact ATD Management to discuss an alternate arrangement/approval if this is a problem.

I understand that ATD will only reimburse up to $6.00 per gallon for fuel purchased for this aircraft while in your possession. I will be charged for the excess for each gallon purchased.

I, as PIC, promise to advise ATD of any abnormalities (both regulatory and aircraft) that occur while this aircraft is in my possession prior to takeoff.

I, as PIC, promise to seek the advice and request approval of ATD before continuation of a flight if an abnormal situation has developed. This is referred to as Crew Resource Management (CRM). I understand that ATD is my “Aircraft Operations and Dispatch Center”, and therefore is here to help me in keeping my flight safe. I will not make decisions on my own when “Out of the Ordinary” situations have developed that may place in question the airworthiness of this aircraft or safety of flight.

I promise that the above statements are true and that I understand what is expected of me while this aircraft is in my possession. I agree to comply with all of the above and will conduct myself as a competent pilot to the best of my abilities while complying with all applicable Federal Aviation Regulations while in possession of this aircraft. [Insert Full Name]