SCHOLARSHIP DESIRED:  (SELECT ONE)

       Private Pilot Scholarship    *Advanced Rating Scholarship

*  Advanced Rating Sought 

FULL NAME OF APPLICANT: 

STREET ADDRESS:     CITY:   

STATE:    ZIP CODE:    E-MAIL: 

PHONE: (INCLUDE AREA CODE) DAY -    EVENING: 

DATE OF BIRTH:    HIGHEST LEVEL OF EDUCATION:

OCCUPATION:   EMPLOYER:

ARE YOU CURRENTLY ENROLLED IN A GROUND SCHOOL COURSE?  YES  NO

IS YOUR GROUND COURSE COMPLETED?    YES  NO             

IF YES, PLEASE INDICATE WHERE AND WHEN: 

HAVE YOU PASSED THE FAA WRITTEN EXAM, IF APPLICABLE, FOR THE RATING YOU ARE SEEKING?  YES  NO

HOW MANY HOURS HAVE YOU FLOWN IN THE LAST 90 DAYS?  

NAME OF FLIGHT SCHOOL?   PRIMARY AIRPORT

INSTRUCTORS NAME   INSTRUCTORS PHONE 

HAVE YOU ACHIEVED YOUR FIRST SOLO FLIGHT?  YES  NO

HAVE YOU ACHIEVED YOUR LONG SOLO CROSS COUNTRY FLIGHT?  YES  NO

 FLIGHT HOURS:  DUAL   SOLO/PIC   CROSS COUNTRY

HOW MANY HOURS OF FLIGHT PER MONTH DO YOU AVERAGE?   

HOW MANY HOURS HAVE YOU FLOWN TOWARD THE RATING FOR WHICH YOU ARE APPLYING?

Neither the Phoenix chapter of the Ninety-Nines, Inc., the Southwest Section of the Ninety-Nines, Inc., nor the Ninety-Nines, Inc., nor their members, agents, or representatives are responsible for the quality of any training received with this scholarship, nor for any accident, incident, or any other event which may occur while the recipient of this scholarship is performing flight training, or activities related thereto. Recipient agrees to sign this Hold-Harmless Agreement in favor of said entities upon receipt of the scholarship and before any flight is made.

I hereby release the Ninety-Nines and any of its affiliated organizations from all actions, claims or demands that I, my assignees, heirs, distributes, guardians, and legal representatives now have or may hereafter have for injury or damage resulting from my participation in any activities related to this scholarship.

I agree to abide by all the terms and conditions specified on this application. I declare under penalty of perjury that the information I have given here is true and correct and that I meet the eligibility requirement for the scholarship sought.

Print this form prior to signing

Applicants Signature   Date 

Please attach written essay, letters of recommendation and copies of required materials, as stated above or in the Fact Sheet.

Print completed application and supporting documentation

Application and supporting documentation shall be submitted by mail to:

Phoenix 99s Scholarship Committee,

10755 W. Belmont Ave.,

Glendale, AZ 85307-1727

Questions? -- deezapilot@cox.net

Postmark deadline is November 1st.

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FACT SHEET