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SECTION 1 - APPLICANT INFORMATION

Name (Last, First)*

Email Address*

Age:*

Mailing Address

Primary Phone*

City

Secondary Phone

Country

Skype ID:

State

English Proficiency: The FAA requires all pilots to read, speak and write english*
Yes, I am fluent in english
I can read, speak and write, but not fluent
Cannot read, speak or write

Please enter your weight in U.S. pounds*
Greater than 205 US Pounds
190 - 205 US Pounds
Less than 190 US Pounds

Zip Code

Program Application

Training Program
Professional Pilot - Certificate Program
Professional pilot - Associate Degree

Training Aircraft:*
Airplane
Helicopter

Term Applying For
Spring 2011
Summer 2011
Fall 2011

Campus Applying to*
Visalia, California Campus

Housing
Yes, I will need housing
No, I don't need housing

High School Education

Name and location of High School

Last Year Attended

Did you Graduate?

High School GPA

Post Secondary Education

Name and location of all college and/or university attended:

Major/Course of study:

Units Completed

Cumulative GPA

Medical History

The Federal Aviation Administration has established regulations regarding the health of pilots. Marking "yes" to any of the conditions below may not automatically disqualify you from participating in the program. However it is essential that our advisors know about any medical condition that may disqualify you from training, so that if a medical waiver is available, we can help you through that process. This information is private and confidential and will not be shared without your written consent or unless required by law.

Have you ever been diagnosed with diabetes?
Yes
No

Are you color-blind?
Yes
No

Have you ever been diagnosed with ADHD, depression, anxiety or been prescribed medication for any of these conditions?
Yes
No

Check all boxes corresponding to medical smyptoms you have ever been diagnosed with:

Frequent or sever headaches

High or low blood pressure

Motion Sickness

Dizziness or fainting spells

Stomach, liver or intestinal trouble

Military medical discharge

Unconsciousness

Kindey stone or blood in urine

Medical rejection by military services

Eye or vision trouble

Neurological disorders: epilepsy, seizure, paralysis, et-al.

Rejection of life or health insurance

Hay Fever or Allergy

Mental disorders of any sort

Other illness, disability or surgery

Asthma or lung disease

Suicide Attempt

Medical Disability

Heart or vascular trouble

Alcohol dependency or drug abuse

If you marked yes to any of the above please provide a brief description below

This information is classified as private data on individuals and will only be used in the evaluation of your application. It will not be shared with any outside organization without your express consent, unless required by law.

IF YOU FAIL TO DISCLUSE THIS INFORMATION IN A TRUTHFUL MANNER YOU WILL AUTOMATICALLY BE DISQUALIFIED FROM CONSIDERATION FOR ADMISSION

Have you ever been convicted of any offense other than a parking ticket?
Yes
No

Have you ever been convicted of an alcohol or drug related offense?
Yes
No

Please provide as much detail as possible regarding each offense, including date and specific conviction

Attestation:
I certify that all of the statements by me in this application are true, complete and correct to the best of my knowledge and are made in good faith. I understand that any false information or omission of information from this application will be cause for rejection or dismissal from the program.*

I understand and agree to these terms
I Do Not Agree

Enter the code shown above

* Required

Aviation Program Application

HELICOPTER courses have a maximum pilot weight of 205 U.S. Pounds, due to aircraft weight and balance restrictions. At completion of course, all helicopter pilots must weigh less than 200 pounds.

Check all boxes corresponding to medical smyptoms you have ever been diagnosed with: