PERSONAL INFORMATION Name Soc Sec # --
Address Date of Birth (MonthDay
Year)
City ,State Zip-
Home Phone () -
Work Phone () -
eMail Adderss EMPLOYMENT INFORMATION Employer
Address
City ,State Zip-
PREVIOUS FLYING & MEDICAL INFORMATION Certificate Number Date BFR Due (MonthDay
Year)
Medical Class
Date Issued (MonthDay
Year)
Limitations
Ratings
Type Aircraft Flown
LOGGED PILOT HOURS
Total Multi
Retract Tail Wheel
Last 12 Months Next 12 Months
Do you have any physical impairments, waivers, limitations
or conditions on you FAA medical certificate?YesNo
Has your FAA or Military certificate ever been suspended?YesNo
Have you ever been cited for violation of a FAR?YesNo
Have you ever been involved in a aircraft accident?YesNo
Have you ever been convicted of or plead guilty to drunken driving,
or felony?YesNo
EMERGENCY INFORMATION Person to Contact
Relation
Phone Number #1 () -
Phone Number #2 () -
For Flight training, each applicant must present proof of Citizenshipto their
flight instructor in the form of a copy of Current US Passport or original copy of
Birth Certificate with raised letters showing on Seal. These must be presented
prior to starting training for any Flight Certificate except Bi-Annuals.
I hereby apply to the West Central Georgia Flying Club and certify
that all information is correct.