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Name
Phone Number
Email
Permanent Resident


Address Line 1
Address Line 2
Suburb
State
Postcode
Date of Birth
Height (cm)

Weight (kg)

Annual Salary
$
Gender

What types of aircraft do you fly?


Licence Number

What make/models of aircraft do you regularly fly?

Are you a member of a pilot union/association?


Have you ever had your licence suspended or cancelled?

Have you ever been convicted of a breach of Air Navigation Safety Regulation?

Have you been involved in an aircraft accident in the last 5 years?

Has any limitation ever been endorsed on your licence?

Have you ever been grounded, declared unft to fy or had your licence invalidated for any medical reasons?


Please estimate the number of hours flying in the next 12 months associated with the following activities:

Have you in the last 10 years suffered from any conditions which necessitated hospital attendance, or admission, or diagnosis, or treatment?


Do you currently Smoke?

Have you in the last 10 years receieved treatment or advice from a registered medical practitioner (including but not limited to a doctor, chiropractor, physiotherapist, psychiatrist or naturopath) in relation to:
Heart, arteries, high cholesterol or high blood pressure or disorders of the circulatory system?


Lungs, asthma, tuberculosis or disorders of the respiratory system?


Kidney, bladder, liver, spleen, bowel or disorders of the genito-urinary system?


Brain, Epilepsy or disorder of the central nervous system?


Stomach, oesophagus or disorders of the digestive system?


Head, back, neck or spine or any disorder of the musculoskeletal system?


Depression, psychological, psychiatric or personality disorder?


Drug or alcohol dependence?


Have you in the last 10 years receieved treatment or advice from a registered medical practitioner (including but not limited to a doctor, chiropractor, physiotherapist, psychiatrist or naturopath) in relation to:
Cancer or tumour?


Diabetes?


Any Disorder of the Eyes or Ears?


Hepatitis?


HIV, AIDS or AIDS related conditions?


Any hernia or associated condition?


Ulcers?


Arthritis or rheumatism?


Physical impairment or deformity?


Any other medical condition, illness or injury which has been diagnosed and for which you have had treatment including accidents involving injury?


Do you intend on engaging in pylon racing?

Do you intend on engaging in record attempts or speed trials?

Do you intend on engaging in any form of flying involving abnormal hazards?

Date of your last Aviation Medical
After or during a medical examination have you ever been required to take additional tests, been referred for specialist examination, had the issue or renewal of your medical deferred, been ordered to take drugs or follow any special diet ?


Do you intend on engaging in fish spotting?

Do you fly outside Australia?

Do you intend on engaging in experimenting with or testing new parts, devices, design or aircraft types, or ultralight aircraft?

Do you currently have any symptoms of injury or illness or are you taking prescribed medication of any kind?