Anson Air - Enrollment Form/pilot Information Sheet
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3Anson Air
Enrollment Form/Pilot Information Sheet
Boy Scout of America - Discovery of Flight
Name: ______________________________
Telephone Number: ______________________
Age:
______
Alternate Number: _______________________
Address:
__________________________
Drivers License Number: __________________
__________________________
__________________________
EMAIL:
__________________________
Occupation: ___________________________
Work Phone: _____________________
Emergency Contact: _______________________ Phone: ______________________
I am a U.S. citizen or have a permanent visa ........................................
Yes
No
I am visiting the U.S. on temporary visa (tourist, student, business etc.) ...
Yes
No
How did you hear about Anson Air? ___________________________________________
From Aviation MB counselor
Within the last 36 months have you:
Been involved in any aircraft accident or incident?
X
Yes
No
Been cited for any FAR violations?
X
Yes
No
Had your pilot or driver’s license suspended or revoked?
X
Yes
No
Been convicted of any felony or DUI charge?
X
Yes
No
Pilot Ratings (circle): Student/none, Private, IFR, Commercial, Multi, CFI, CFII, MEI, ATP
N/A
N/A
Total Logged Hours: ________ Retractable gear hours: ________ Multi hours: ________
N/A
N/A
Date of Last FAA Medical: ________________
Class: I, II, III
N/A
Waivers or limitations on your FAA medical: _________________________________________
N/A
Date of last Biennial Flight Review or Flight Test: _____________
By signing this, which becomes part of your Rental Agreement, you are certifying that the above
information is true and accurate to the best of your knowledge and that you have read the terms on the
reverse side.
Signature: _______________________________ Date: ______________
If you are under 18 years of age, a parent or guardian signature is also required:
Signature: _______________________________ Date: ______________
form revised 07/05/05
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