Application & Pilot Information Form
Information required for American Aero Club (AAC)
Email address *
Personal Info
We'll need this information to have on file to fly with us
First Name *
Your answer
Last Name *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Email Address *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Birthday *
Please put in the actual date of birth including year
MM
/
DD
/
YYYY
Citizenship *
Your answer
Employment Information
Employer & Occupation *
Your answer
Business Phone *
Your answer
Emergency Contact Information
Emergency Contact Name and Relation #1 *
Your answer
Emergency Contact Phone #1 *
Your answer
Emergency Contact Name and Relation #2 *
Your answer
Emergency Contact Phone #2 *
Your answer
Medical Information:
Medical Cert Class *
Medical Issue Date (if N/A or BasicMed use today's date) *
MM
/
DD
/
YYYY
Medical Expiration Date (if N/A or BasicMed use today's date) *
MM
/
DD
/
YYYY
Issuing AME: (if none fill in "none") *
Your answer
Pilot Certificates and Ratings
Date Of Issue *
MM
/
DD
/
YYYY
Certificate Type *
Certificate Number *
Your answer
Category and Class Ratings (ASEL, AMEL, Student, etc.): *
Your answer
Do you have an instrument rating? *
List any endorsements (complex, high performance, etc.)
Your answer
Total Time
Your answer
Last Flight Review Date
MM
/
DD
/
YYYY
Renter's or Non-Owners Insurance Information
Renter's or Non-Owners Insurance Policy # *
Your answer
Insurance Expiration Date *
MM
/
DD
/
YYYY
Renter's or Non-Owners Ins. Company Name
Your answer
Insurance Agent Name *
Your answer
Insurance Agent Phone Number
Your answer
Other Information
Billing Option *
Have you ever had your Airman's Certificate revoked or suspended? (if yes, please explain) *
Your answer
Have you ever had an accident or incident? (if yes, please explain) *
Your answer
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