Please answer the following questions:

1. What is your primary purpose in applying for pilot training?

2. Have previously been issued any type of of pilot's license? yes no

3. If you answered yes in the previous question, please state the type of license number, ratings, issuing authority, date of issue, and period of validity.

4. Have you ever been penalized for any infraction of Civil Air Regulations? yes no

5. Have you ever been involved in an aircraft accident or incident as a crew member? yes no

6. Do you have any physical, medical or neurological condition that may affect your ability to safety act as a pilot of an aircraft? yes no

7. Have you ever been convicted of any crime involving moral turpitude? yes no

8. If you answered yes from 4 to 7, please state the circumstances briefly.

I hereby certify that all entries I have made above are true and correct to the best of my knowledge