CANDIDATE INFORMATION WORKSHEET

AUTHORITY: 10 U.S.C. 8013, Secretary of the Air Force; powers, duties, and delegation, as implemented by AFI 36-2605, Air Force Military Personnel Testing System, Executive Order 9397 (SSN) and Executive Order 13478 (PII).

PURPOSE: Used to process and track Test of Basic Aviation Skills (TBAS) results.

ROUTINE USES: For use in Pilot Training Selection and for DOD research.

DISCLOSURE:Voluntary - Failure to provide SSN will result in disqualification for TBAS testing and Pilot Training Candidacy

PLEASE COMPLETE THIS WORKSHEET BY ENTERING THE APPROPRIATE INFORMATION

1.NAME: FIRST_____________, MI ____LAST_________________.††

2.SSN: _____-____-_______

3.SEX (M/F): _____ ††††††††††† 4.DATE OF BIRTH (MM/DD/YYYY): _______________

5.Ethnicity: ____ Hispanic or Latino††††††††††††††††††††††††††††† ____ Not Hispanic or Latino

6.Race (Check all that apply)

____ American Indian or Alaska Native††††††††††††††††††††††††† ____ White††††††††††

____ Native Hawaiian or Other Pacific Islander††††††††††††____ Asian

____ Black or African American

7.CHECK THE ENTRY THAT REPRESENTS YOUR HIGHEST LEVEL OF EDUCATION OBTAINED:

_____HIGH SCHOOL GRADUATE†††††††††††††††††††††††††††††††† _____1 YEAR COLLEGE

_____2 YEARS COLLEGE††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††† _____3 YEARS COLLEGE

_____UNDERGRADUATE DEGREE††††††††††††††††††††††††††††† _____MASTERS DEGREE

_____DOCTORATE DEGREE

8.ENTER EDUCATION INFORMATION:

†††††††† UNDERGRADUATE INSTITUTION:________________________________________

†††††††† UNDERGRADUATE MAJOR:______________________________________________

BASED ON A 4-POINT SCALE, ENTER YOUR CURRENT CUMULATIVE GRADE POINT AVERAGE TO TWO DECIMAL PLACES (E.G., 3.25).  YOU WILL BE ASKED TO SHOW THE TEST EXAMINER YOUR CURRENT TRANSCRIPTS.____________

9.CHECK THE ENTRY INDICATING YOUR HIGHEST AERONAUTICAL RATING:

†††††††† _____NONE††††††††††††††††††††††††††††††††††††††††††††††††††† _____STUDENT PILOTíS LICENSE

†††††††† _____PRIVATE PILOTíS LICENSE††††††††††††††††††††††† _____COMMERCIAL RATING

†††††††† _____AIRLINE TRANSPORT RATING

10.CHECK THE ENTRY THAT INDICATES YOUR CURRENT STATUS

†††††††† _____†† AF ACADEMY CADET†††††††††††††††††††† _____ROTC CADET/APPLICANT

†††††††† _____OTS APPLICANT (ENLISTED)†††††††† _____OTS APPLICANT CIVILIAN

†††††††† _____ACTIVE DUTY OFFICER††††† _____ANG PILOT TRAINING APPLICANT

†††††††† _____AF RESERVE PILOT TRAINING APPLICANT†††††

††††††††† _____NONE OF THE ABOVE

11.CHECK THE ENTRY INDICATING YOUR COMMISSIONING SOURCE:

†††††††† _____AF ACADEMY††††††††††† _____ROTC _____OTS†††† _____OTHER

12. CHECK THE ENTRY(S) REPRESENTING THE TYPE(S) OF AIRCRAFT IN WHICH THE FLYING HOURS YOU INDICATED IN QUESTION 9 WERE ACCUMULATED.

†††††††† _____FIXED WING†† ††††††††††† _____ROTARY WING†††††† _____SINGLE ENGINE

†††††††† _____MUTLI ENGINE††††††††† _____INSTRUMENT††††††††† _____ OTHER†††††††††††

††††††††† _____CERTIFIED FLIGHT INSTRUCTOR†††††††††††††††††††††††† _____NOT APPLICABLE

 

13.FILL IN THE FOLLOWING ABOUT YOUR CURRENT RESIDENCE:

†††††††† ZIP CODE _____________

†††††††† CITY, STATE____________________

 

 

14.ENTER THE TOTAL NUMBER OF INSTRUCTIONAL AND PILOT IN CHARGE FLYING HOURS YOU HAVE FLOWN AS A LICENSED AND/OR UNLICENSED PILOT.YOU WILL BE ASKED TO SHOW TH E TEST EXAMINER YOUR PILOT LOGBOOK BEFORE TAKING THE TBAS TEST._____________

15.AFOQT TEST LOCATION (OPTIONAL)________________________________________

16.EMAIL ADDRESS (OPTIONAL)______________________________________________

17.HAVE YOU EVER TAKEN THE TBAS BEFORE?†††† YES _____††††††††††† NO ____†† IF YES, WAS THE TEST WITHIN THE LAST SIX (6) MONTHS?YES _____††††††† NO _____††††† IF YOU ANSWERED YES TO EITHER QUESTION INFORM THE TEST EXAMINER.†††† IF NO PROCEED.

18.DO YOU UNDERSTAND THE TBAS CAN ONLY BE TAKEN TWICE IN YOUR LIFETIME?††††††††††††††††††

†††††††† YES _____†††††† NO _____†† IF YOU ANSWERED NO CONTACT THE TEST EXAMINER†† IF YES CONTINUE.

TO THE BEST OF MY KNOWLEDGE I AM PHYSICALLY AND EMOTIONALLY FIT TO TAKE THE TEST OF BASIC AVIATION SKILLS TEST BATTERY TODAY.

I UNDERSTAND ONE RETEST OF THE TBAS IS ALLOWED AFTER 180 DAYS FROM THE ORIGINAL TEST DATE HAVE PASSED.I AM NOT AWARE OF ANY PHYSICAL OR MENTAL CONDITION (i.e., PERSONAL STRESSES, SICKNESS, LACK OF SLEEP, ETC) WHICH WILL NEGATIVELY IMPACT MY ABILITY TO PERFORM UP TO MY ABILITY ON THE TBAS.I ACKNOWLEDGE IF I DO TAKE THE TBAS A THIRD TIME WITHOUT AN APPROVED WAIVER, I WILL BE DISQUALIFIED FROM CONSIDERATION FROM AIR FORCE PILOT TRAINING.

I VERIFY THAT THE INFORMATION ON THIS CANDIDATE INFORMATION WORKSHEET IS CORRECT. I UNDERSTAND THAT FALSIFICATION OF ANY OF THE INFORMATION ON THIS WORKSHEET WILL RESULT IN MY DISQUALIFICATION FROM CONSIDERATION FOR AIR FORCE PILOT TRAINING.

I UNDERSTAND THAT DISCUSSING THE CONTENTS OF THIS TEST WITH ANYONE OTHER THAN THE TEST ADMINISTRATOR WILL RESULT IN MY DISQUALIFICATION FROM CONSIDERATION FOR AIR FORCE PILOT TRAINING.FURTHER, I UNDERSTAND DISCUSSION OR DISCLOSURE OF CONTROLLED TEST MATERIAL IS A VIOLATION OF ARTICLE 92, UCMJ, PUNISHABLE BY UP TO 2 YEARS HARD LABOR AND A DISHONORABLE DISCHARGE.

CANDIDATE'S SIGNATURE ________________________________________________

DATE †††††††††††††††††††††††††††††††††††††††††_______________________________________________