MITCH PENNINGTON [email protected] 304-703-5898
CHECKRIDE REQUEST FORM
DATE REQUESTED: TIME REQUESTED: TEST LOCATION REQUESTED:
TYPE OF TEST REQUESTED: INITIAL TEST
RETEST
PART 61
PART 141
ADDRESS ON PILOT LICENSE:
PHONE #: E-MAIL:
APPLICATION #: FAA TRACKING # (FTN):
PILOT CERT #: GRADE OF CERTIFICATE HELD: CATEGORY, CLASS RATINGS:
ASEL AMEL
ASES AMES
MEDICAL CLASS: CLASS DATE: PRIMARY TRAINING AIRPORT:
RECOMMENDING INSTRUCTOR INFORMATION
INSTRUCTOR'S PHONE #:
INSTRUCTOR'S E-MAIL: INSTRUCTOR'S CFI #: CFI EXPIRATION DATE:
AIRCRAFT INFORMATION
REGISTRATION:
INSTRUCTOR'S FULL NAME:
MAKE & MODEL:
HOME BASE:
APPLICANT INFORMATION
FULL NAME:
STUDENT
CFI
PVT
COMM
LOD
CODE DEFINITIONDEFICIENT
PLT/ACS CODE
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
KNOWLEDGE TEST INFORMATION
1.
TEST SCORE:
Recommended
