General Information - Part 1

Full Name:

Email Address:

Phone: ie., (555) 555-5555

Address:

Address 2:

State/Province:

Zip/Postal Code:

Country:

Emergency Contact Information - Part 2

Full Name:

Email Address:

Phone: ie., (555) 555-5555

Address:

Address 2:

State/Province:

Zip/Postal Code:

Country:

Relationship:

Personal Information - Part 3

Gender: Male Female

Height: inches

Weight: pounds

Date of Birth: (mm/dd/yyyy)

Place of Birth:

Citizenship:

Social Security Number: (123-45-6789)

Marital Status: MarriedSingle

Personal Information (Continued) - Part 4

High School GPA:

Recent College GPA:

Driver License Number:

Driver License Issued by State:

Occupation:

School Record - Part 5

List three most recent schools attended (High School, University or Technical)

School Name:

School Location:

Dates Attended:

Diploma/Degree:

School Name:

School Location:

Dates Attended:

Diploma/Degree:

School Record Continued - Part 6

School Name:

School Location:

Dates Attended:

Diploma/Degree:

Flight Experience - Part 7

Total Time:

PIC Total:

Solo Total:

Night Total:

Instrument Total:

Multi Total:

Dual Given Total:

Flight Experience Continued - Part 8

List ALL flight certificates and ratings held:

Name and location of school where certificates and ratings were obtained:

Medical Information - Part 9

FAA Medical: 1st Class2nd Class3rd Class

Date of issue:

Has your medical ever been denied or revoked?: NoYes

If Yes, please explain:

Additional Information - Part 10

Is English your Native Language?: YesNo

If NO, do you read, speak and understand English?: YesNo

Drug/Alcohol conviction within the past 12 months?: YesNo

If yes, explain:

Additional Information Continued - Part 11

What courses are you enrolled in?:

Desired start date:

Student Housing Request?: YesNo

Do you smoke?: YesNo

Enrollment Completion - Part 12

I certify that the above statements are correct and complete. I understand that I must complete the following items to register for any course with Daytona Aviation Academy:

Completed Enrollment Form	Copy of last totaled pages of logbook
Signed Flight Training & Rental Contract	Signed Credit Card Imprint
Copy of FAA Medical Certificate	Issued Safety Policies & Procedures
Copy of FAA/JAA /CAA Pilot License	TSA Docs
Copy of government Issued Photo ID	Proof of Aircraft Rental Insurance
Copy of Passport (international students only)	Check-in and Check-out

If you are under 18 years of age, you must have a Parent/Guardian complete, sign, and fax/mail the application.

Electronic Signature: