Event Registration

First Name: Last Name: Email: Day Phone: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Current Employer Occupation/Job Title How long have you been with your current employer? Aircraft A319/320/321 BELL206 B737 B757/767 B777 C152 C172 CL65 CRJ200/700/900 EMB170/175/190 ERJ140/145 HC130 HC144 MD10/11 MD88 PC12 Total logged pilot flight hours (civilian or military) Certificates/Ratings What is your FAA Certificate Number? What is the Date of Issue for your FAA Certificate? What is your Class of Medical Certificate? Third-Class Second-Class First-Class What is the Date of Examination of your FAA Medical Certificate? (MM/DD/YYYY) Instructor Certificates Are you currently working as a ground/ flight instructor? Yes No Previous/Current University and/or Flight School Attended? Branch of Service Army Navy Air Force Marines Coast Guard Are you currently, or have you previously been, a part of an aviation pipeline program? Yes No If you were or are a part of an aviation pipeline program, which one was it? Are you a part of the Luke Weathers Flight Academy? Yes No Which Mentorship Program are you applying for? Year-long and Accelerated Mentorship Programs Were you in the mentorship program in a previous year? Yes No If you were in the mentorship program in a previous year, which year was it? What is your overall goal in Aviation? What do you hope to obtain from the Mentorship Program? I understand that the $15 application processing fee is non-refundable. Yes I understand that this mentorship program is for individuals who identify as female. I identify as female. Yes No I understand that this mentorship program is for women of color. If you identify as a women of color, what do you identify as? Black or African American Asian Hispanic or Latino American Indian or Alaska Native Native Hawaiian or Other Pacific Islander White Captcha