General Information Name (Family / Surname) Last First Middle Note: If you do not have a First or Middle name put XXXX in the box. Address Telephone (home)   Telephone (work)   Telephone (Fax)   E-mail address   Country of Birth Country of Citizenship Date of Birth (Mo/Da/Yr) City of Birth Weight (lbs) Height (inches) Marital Status Do you need a Student Visa? Yes No Emergency Contact Information Name Address and Phone number Previous Flight Experience (If Any) Do you currently hold an FAA Pilot Certificate? Yes No If Yes, please specify the type of certificate and ratings held Do you currently hold an ICAO Pilot Certificate (other than FAA)? Yes No If Yes, please specify the licensing country, the type of certificate and ratings held Do you hold a valid FAA Medical Certificate? Yes No If Yes, please specify: 1st Class 2nd Class 3rd Class Records of Pilot Time:   TOTAL  Instruction Received  Solo  Pilot in Command  Second in Command  Cross- Country Instruction Received  Cross- Country Solo  Cross- Country Pilot in Command  Instrument  Night Instruction Received  Night Takeoffs and Landings  Night Pilot in Command  Night Takeoffs /Landings Pilot in Command  Airplanes Rotorcrafts Total Multi-Engine Flight Time: Schools attended, locations, programs, dates:   Military Background (If Any) Branch: Rate: Months of Active Duty: Last Day of Duty or E.T.S.:   Program Desired Please specify the type of training program you would like to follow... Professional Pilot Program (200hr Multi-Engine Course)* Commercial Pilot Program (NO Instructor ratings)* VA Individual Courses 100 hours Multi-Engine/Instrument Rating Course “Twin Time” Program (100 hours of Multi-Engine) VA Professional Pilot Course Individual Course (Please Specify):        **A Copy of your High School diploma or GED is MANDATORY if Enrolling in one of our Professional Pilot Courses.** Date at which you would desire to start your training: *Required (mm/dd/yyyy)   Educational Background School, State From (Month/Year) To (Month/Year) Area of Study Certificate, Diploma or Degree Earned Copy of Diploma (Yes/No)* (*) High School and College Graduates must send a copy of your diploma if you wish to be enrolled in the Pro Course We Must Receive your Deposit before Application will be Processed