* = Required Field
ENROLLMENT FORM
Date of Training * (Mo / Day / Year)
Type of Training Requested *
TYPE OF TRAINING Combo Courses Interview Profile Type Rating Jet Transition Course Flight Engineer Rating Maintenance Taxi and Run Up Flight Attendant
Name (Last, First, Middle) *
SSN (US Only)
Date of Birth (Mo / Day / Year) *
Place of birth (City, State, Country
Eyes *
Eye Color Brown Blue Green Hazel Black
Height
Weight
Hair
Permanent Address
City
State
Zip
Country
Sex *
Sex Male Female
Citizenship *
Do you read, write and understand English?
Home phone
FAX number
Cell Phone
E-mail address *
Have you ever been convicted for violation of any Federal or State statutes relating to narcotic drugs, marijuana, depressant or stimulant drugs or substances?
Yes No Date of final conviction:
Certificates Held
ATP Commercial Flight Engineer
Ratings
Multiengine Instrument Turbo Prop Reciprocating Turbo Jet
Type Ratings Held
Have you operated an aircraft heavier than 12,500 lbs during the past 12 months?
Yes No If yes, which one?
If this course is part of an original ATP issuance, please complete the following time information. If you already hold an ATP, please continue to the next section.
TOTAL HRS
INSTRUCTION RECEIVED
SOLO
PILOT IN COMMAND
CROSS COUNTRY INSTRUCTION RECEIVED
CROSS COUNTRY PIC
INSTRUMENT
NIGHT INSTRUCTION RECEIVED
NIGHT TAKE-OFF LANDING PIC
NIGHT PIC
If applicable, please provide the requested certificate numbers, aircraft type, position flown and total hours.
Certificates
Number
Private Pilot
Flight Instructor
ATP
FE Prop Jet
Commercial Pilot
Airframe
Multi - Land
Powerplant
Instrument
Dispatch
Ground Instructor
Radio Operator
Aircraft Type
Position Flown
Total Hours Flown
Tuition Deposit: By submitting this form I authorize Aeroservice Aviation Center to charge my credit card for the Tuition Deposit amount indicated below. I understand that this amount will be applied to my account in full and is not refundable. In the case of a cancelation I may apply these funds to any other course offered by Aeroservice Aviation Center within 12 months of the date of this enrollment form.
Select Amount *: AUTHORIZED CHARGE AMOUNT Remove Circle: $825 Discovery Simulator Flight - $750.00 Profile deposit: $750.00 Profile deposit: $1,200.00 Type Rating Deposit: $1,500.00 Jet Transition Course Deposit: $1,500.00 Flight Engineer Deposit: $1,500.00 Flight Attendant Deposit: $1,500.00 WIA - Certificate received
Credit Card *: CARD TYPE Visa Master Card American Express Discover
Card Number *:
For your protection, we ask that you enter an extra 3-4 digit number called the CCID. The CCID is NOT your PIN number. It is an extra ID printed on your Visa, MasterCard, Discover, or American Express Card.
Security Code *:
Expiration Date *: MONTH January February March April May June July August September October November December YEAR 2008 2009 2010 2011 2012
Electronic Signature (Please type your name here) *:
By submitting this form I certify that all statements and answers provided by me on this application are complete and true to the best of my knowledge and I agre that they are to be considered as part of the basis for issuance of any FAA or Company certificate to me.
