Legal Name

Date

Address

City

State:

Zip

Country

Phone Number

Fax or Email

RATINGS INFORMATION

List all ratings that you currently hold

Where did you receive your previous flight training

Do you currently have medical and if so what class

List all types of aircraft flown

Flight Hours

What Class Date are you enrolling in?

First choice Second choice

BY SUBMITTING THIS ENROLLMENT APPLICATION, I AGREE THAT I WILL ATTEND THE AGRICULTURAL PILOT TRAINING PROGRAM BEGINNING ON THE ABOVE MENTIONED DATE. I FURTHER UNDERSTAND THAT ALTHOUGH EVERY EFFORT WILL BE MADE TO TRAIN ME IN A TIMELY FASHION THAT THE AMOUNT OF TIME TAKEN TO TRAIN EACH INDIVIDUAL MAY VARY ACCORDING TO EACH INDIVIDUAL’S ABILITY. I ALSO UNDERSTAND THAT THERE IS NO REFUND ON ANY AGRICULTURAL TRAINING PROGRAMS SHOULD I DECIDE TO LEAVE AFTER ENROLLING IN THE TRAINING PROGRAM. I UNDERSTAND THAT IF, DUE TO EMERGENCY, OR OTHER UNFORESEEN OCCURRENCES, I MUST LEAVE THE PROGRAM FOR ANY LENGTH OF TIME, THAT I WILL BE ABLE TO RETURN AT A LATER MUTUALLY AGREED UPON DATE TO FINISH MY TRAINING. I ALSO UNDERSTAND THAT THE SAM RIGGS AGRICULTURAL PILOT TRAINING CENTER, LTD. (BELIZE) HAS A NO DRINKING AND NO DRUG USE POLICY AND I AGREE TO REFRAIN FROM DRINKING OR USING DRUGS UPON ANY SAM RIGGS AGRICULTURAL PILOT TRAINING FACILITY AND THAT ANY USE OF ANY ILLEGAL SUBSTANCE WILL RESULT IN THE TERMINATION OF MY ENROLLMENT.

EMERGENCY CONTACT INFO

Name

Relationship

Address:

City:

State:

Zip:

Phone #:

Fax:

Email:

Comments:

NOTE TO FOREIGN STUDENTS If you want us to issue you a Student Visa Form I-20 M-1 good for attending our school and working in the U.S. for up to 12 moths in the field of Agricultural Aviation please provide us with the following information: Full Legal Name, Date of Birth, Country of Birth, Country of Citizenship, and the Amount of U.S. Dollars you will be bringing into the Country. The Visa will not be issued unless you include your deposit (a cashier’s check or money order in the amount of $ 500.00 USD)

ALL STUDENTS In order for your enrollment to be accepted, a deposit in the amount of $500.00 USD must be accompanied with this enrollment form. All deposits must be in the form of cashier’s check, or money order (no personal checks accepted) and will be applied towards your tuition upon arrival. Failure to appear at the scheduled time without making previous arrangements will result in the forfeiture of your deposit.

This Space for Office Use Only:

Dep. & Enrollment Form Rec’d Date_________________________________________________________________

Initial Courses Selected ___________________________________________________________________________

Balance Due Date________________

Paid_______________

Medical Information: 1st Class 2nd Class 3rdClass

Examining Doctor Date_______________________________

Issued Pilot License Information _______________________

Date Issued _________________

Other Ratings Held ________________________________________________________________________________