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