Practical Test Request – Aram Basmadjian

Applicant Name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

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Telephone *

Pilot Certificate # *

Email *

IACRA FTN# *

Name of Recommending Instructor *

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Recommending Instructor's Telephone Number *

Recommending Instructor's Certificate Number *

Recommending Instructor's Email *

Flight School (if applicable)

Practical Test Requested *

Type of Test *

Date of Notice of Disapproval / Letter of Discontinuance

Graduate of Part 141 School? *

Graduation Date from Part 141 School (if applicable) *

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Aircraft Make & Model *

Aircraft N#

Type of GPS installed in Aircraft (if applicable)

Type of Aircraft Instrumentation installed in Aircraft

Flight Review

Date of 61.56 Flight Review or date of successful Practical Test for a Pilot Certificate or Rating, whichever is most recent (if applicable).

Medical Certificate *

Do you have a certificate from an FAA approved Medical Education Course (MEC)

If yes, the certificate must be brought to the Practical Test in either electronic or paper form.

Have you held a medical certificate at any point after 7/14/2006 and the certificate has not been suspended or revoked?

Has your most recent application for an airman medical certificate submitted to the FAA been completed and has not been denied?

If an authorization for a Special Issuance medical was issued, has it been withdrawn?

Test Location *

Check only one box

Test Location – Other *

Preferred Location for Practical Test – Airport Identifier only

Preferred Date of Test *

Availability on Saturday and Sunday ONLY