Domestic Application Form - Southern Wings

1. Course Information

A. Intake*

February
July

B. Location*

Invercargill
Auckland

C. New Zealand Diploma in Aviation - Fixed Wing

Airline
General Aviation
Flight Instructor
Theory Only
Instrument Rating Only
Instructor Rating Only
Casual

2. Personal Details

Applicant

Name*

Title Given Names Preferred Name Family Name

Address*

Street Address Address Line 2 City Region ZIP / Postal Code Country

NZQA Number

Date of Birth*

Home Phone

Mobile Phone*

Email*

Gender

Male
Female

Nationality

Ethnicity

Country of Citizenship

Iwi Affiliation

Citizen of New Zealand

Permanent Resident of New Zealand

Next of Kin

Name*

First Last

Relationship*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone*

Email*

What was your main activity or occupation in New Zealand at 1 October last year?

(tick only one box)

Will this be the first year you have ever enrolled in a University, Polytechnic, College of Education, Private Training Establishment, or Wananga either in New Zealand or overseas since leaving school?

Yes
No

Do not include enrolments in Star, community or hobby classes.

Please enter the year of your first enrolment

3. Education

Are eligible for first year free fees?*

Yes
No
I don't know

What was the name of the last secondary school you attended?*

(state “overseas” if applicable)

What was your last year at secondary school?*

What is the highest level of achievement you hold from a secondary school?*

No secondary qualification/less than 12 credits level 1
14 credits or more at any level
School Cert (one or more subjects) 12 or more credits @ level 1 or above
University Entrance/National Certificate level 2
A or B Bursary/National Certificate level 3
University Scholarship
Overseas award (Includes INT. Bacc.)
None of the above

Your highest achievement may be a traditional award such as School Certificate or you may have achieved a number of credits. Please attach evidence of all transcripts/certificates obtained on previous study.

What year did you attain your highest secondary qualification?*

NCEA 3 or Equivalent

Subject	Grade

4. Previous Flying Experience

Licence held

CPL
PPL

Ratings held

Night
Instrument
Multi
Instructor

Aircraft Ratings

Total Hours

PIC Hours

Exam Credits

CAA Client No

Previous Training Organisation

5. Fit and Proper Declaration

Have you previously had an application for an aviation document rejected or have you been the holder of an aviation document which has been suspended or revoked?*

Yes
No

(other than a licence that has been suspended by a replacement or higher licence)

Please give details below

Have you been convicted of any transport safety offence?*

Yes
No

Are you presently facing charges for a transport safety offence?*

Yes
No

Have you been convicted on any criminal charge or are you presently facing charges for an criminal offence?*

Yes
No

Have you had a history of physical or mental health or serious behavioral problems?*

Yes
No

If you have answered “yes “ to any of the above, please provide details below

6. Medical

Do you have a current Class 1 Medical Certificate?*

Yes
No

If you answered “no”, all applicants will be required to get this medical clearance and forward this to Southern Wings prior to course commencement.

If you answered “no” please indicate if you have any of the following conditions

Asthma
Migraines
Colour Blindness
Other

7. How Did You Hear About Us?

Internet
Publication/Magazine
Printed Newspaper
Agent
Career Seminar/Expo
Word of Mouth
Careers Advisor/School

8. Declaration*

I declare that to the best of my knowledge, all the information supplied is true and correct. I give consent to the disclosure of the personal information above.

Signature

Highest School Results