3800 St Lucie Blvd, Fort Pierce, Florida 34946, 772-466-4822

Application for Enrollment

Course Details
Programs
Semester
Program
Desired Start Date
Type of Course
Course
Visa Required
Deposit Information
Home address
Street
Borough
City
State
Zip
Country
Telephone (Home)
Telephone (Work)
Telephone (Cell)
Emergency address
Emergency Contact
Street
Borough
City
State
Zip
Country
Telephone (Home)
Telephone (Work)
Telephone (Cell)
Personal Details
First Name
Middle Name
Last Name
Email Address
Country of Birth
Country of Citizenship
Date of Birth
City of Birth
Race
Sex
Weight (lbs)
Height (ins)
Marital Status
Occupation
Military Background
Branch
Rank
Months of Active Duty
Last Day of Duty or ETS
Previous Flight Experience
FAA Pilot Certificate Held
FAA Medical Held
ICAO Pilot Certificate Held
ICAO Country

Record of Pilot Time
Total Instruction Received Solo PIC Cross- Country Instruction Received Cross- Country Solo Cross- Country PIC Instrument Night Instruction Received Night Takeoffs and Landings Night PIC Night Takeoffs / Landings PIC
Airplanes
Rotorcrafts

Educational Background
School, State From (Month/Year) To (Month/Year) Area of Study Certificate,
Diploma or
Degree Earned		 Copy of Diploma
(Yes/No)*

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