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Please fill out all items in full, typing or printing legibly in ink. Your signature is

required on page two. Use additional sheets if necessary.

Email Address ___________________________________________

Date of solo sign-off, if any: ______________________

Written test passed: Y / N Date: ________________________

Ratings, if any: ________________________________________________________________

Airman certificate number, if any; ________________________________________________

Medical class and expiration date, if any: __________________________________________

Date of most recent flight review, if any: ___________________________________________

Total flight time: ______________________ PIC: ___________________________

Education level achieved: ________________________________________________________

Other related aviation education, if any: ___________________________________________

Rating(s) sought: _______________________________________________________________

Current Flight School and/or Instructor Name & Number:____________________________

______________________________________________________________________________

Professional or aviation organizations of which you are a member: _____________________

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1. The scholarships will be paid directly to the flight school and/or

independent flight instructor conducting the training. Receipts

showing hours flown and signed by both student and instructor must

be submitted before funds are dispersed.

2. Recipient agrees to complete the certificate/rating within one (1) year

of receipt of scholarship award. If the recipient does not complete the

certificate/rating appropriate to the award within one year of the

award date, the recipient’s status will be reviewed. Special

circumstances will be considered. Copies of the Logbook should be

provided monthly along with a report from the instructor.

3. Any unused monies will revert to the Arizona’s Aviation Hall of

Famer Joe LaPlaca Scholarship Fund.

4. Only one scholarship will be awarded per rating or certificate per

person. (Upon the Fund Director’s discretion.)

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Neither the Arizona’s Aviation Hall of Famer Joe LaPlaca Scholarship Fund 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 his Hold Harmless

Agreement in favor of said entities upon receipt of the scholarship and before any flight is made.

I hereby release the Arizona’s Aviation Hall of Famer Joe LaPlaca Scholarship Fund 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 that I have given here is true and correct and that I meet the eligibility

requirements for the scholarship sought.

________________________________________________________ _______________

APPLICANT SIGNATURE DATE

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1. Written exam if applicable.

2. Medical current.

3. Essay about yourself (your goals, why you would like a scholarship, background

about yourself)

4. Two letters of recommendation

5. Financial need

The Arizona’s Aviation Hall of Famer Joe LaPlaca Scholarship Fund looks at all aspects

of the applicant’s background, goals and need. The award will be given based on all

criteria with an emphasis on financial need, so we encourage all to apply.