Student Intake – Pragmatic Pilot

Personal Information

Last Name

First Name

Date of Birth

Phone Number

Email Address

Mailing Address

City

State / ZIP

Emergency Contact Name

Emergency Contact Phone

Medical Certificate

Issue Date

Expiration Date

Limitations or Special Issuance Notes

Flight Experience

Total Flight Hours

Hours Last 12 Months

Instrument Hours (Actual / Hood)

Primary Aircraft Flown

Hours in Type

Glass / EFIS Experience

Yes No

Aircraft You Own or Regularly Fly

Make & Model

N-Number

Year

Avionics / Panel Notes (e.g., Garmin G1000, Perspective+, Avidyne)

Based At (Airport / ICAO)

Ownership

Owned Partnership Club / Rental

Insurance in Force?

Yes No

Referral & Acknowledgment

How Did You Hear About The Pragmatic Pilot?

Referred By (Name, if applicable)

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that The Pragmatic Pilot reserves the right to decline or discontinue training at any time for safety-related reasons. I accept responsibility for maintaining currency of my medical certificate and ensuring my aircraft is airworthy prior to any dual instruction.

Student Signature *

Date *

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