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Prestige Worldwide Aviation, LLC

Club Membership Application

Personal Information

Date of Birth
Month
Day
Year

Vehicle:

State

Drivers License:

State Issued
Are you a US Citizen?

Insurance Information

Have you Ever had your FAA or DOT certificate suspended or revoked?
Have you ever had an aircraft accident, incident, or violation?
Has any aviation insurance company cancelled, declined, or refused you insurance?

Have you ever been convicted or plead guilty to any of the following?

Reckless driving?
Driving under the influence of alcohol or drugs?

Has your driver's license ever been suspended or revoked?
Have you ever been convicted or under indictment for action involving drugs or narcotics?
Have you ever been convicted of a felony?

Pilot Information

Date Issued
Month
Day
Year
Type of Certificate
Ratings Held
Instructor Certificates/Ratings

If you were referred, please let us know the name of the member

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