Flight Instructor Application Form – BATESVILLE ASSOCIATION OF AVIATORS

First Name

Enter your first name as it appears on your identification.

This field is required.

Last Name

Enter your last name as it appears on your identification.

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Email Address

Provide a valid email address for communication.

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Phone Number

Enter your contact number including area code.

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Address

Provide your complete mailing address.

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

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Airmen Certificate Number:

This field is required.

Certifications (please mark all that apply)

Sport Pilot

Private

Commerical

ATP

CFI

CFII

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Ratings (please mark all that apply)

SEL

MEL

SES

MES

Instrument

Other

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Endorsements (please mark all that apply)

Tailwheel

Complex

High Performance

Other

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Class of Medical (Please mark all that apply)

Class 1

Class II

Class III

BasicMed

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List any restrictions (e.g. Corrective Lenses, etc.) if applicable

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Flight Hours

Enter the total number of flight hours you have logged.

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Instruction Hours

Enter the total number of instruction hours you have logged.

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Flight Hours in Cessna 150/152

Enter the total number of hours you have logged in a Cessna 150.

This field is required.

Flight Hours in other high wing aircraft

Enter the total number of hours you have logged in any other high wing aircraft (please specify model and type).

Date of Last Flight Review:

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Have you ever had a violation against your pilot certificate?

Yes

No

This field is required.

Have you ever had an incident or accident involving an aircraft, reported or not?

Yes

No

This field is required.

Have you ever had your Driver’s license suspended or revoked?

Yes

No

This field is required.

Have you been convicted of a crime or are you under investigatipon of a crime?

Yes

No

This field is required.

Have you ever been convicted of any drug related activity, including DUI/DWI?

Yes

No

This field is required.

Have you been involved in any road accidents in the past 5 years?

Yes

No

This field is required.

Have you ever been denied insurance of any kind?

Yes

No

This field is required.

If you answered, Yes, to any of the above, please explain in detail here or if you prefer to disclose during the interview or if you answered, No, to every question you may leave blank.

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Availability for Instruction

Describe your availability (days and times) for instructing including what date you’d be able to start.

Any special requests, accomodations, or comments?

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Preferred Contact Method

Select your preferred method of contact.

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