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Please provide the following information:

Name  
Street Address  
Address2
City
State

Zip

Occupation
Company
Work Phone
Home Phone
FAX
E-mail
DOB
Recommended by
Type of Ratings Held
Certificate #
Date of Last BFR -- mm/dd/yy
Date of Last Medical -- mm/dd/yy
Date of Last Flight -- mm/dd/yy
Hours to date
Hours last 12 months
Expected hours
next 12 months
Aircraft you are Qualified in
1. Have you been a member in another flying club?  Yes No
If yes, which ones?
2. Have you ever been found in violation of the Federal Aviation Regs?  Yes No 
3. Has your license ever been suspended or revoked?  Yes No 
4. Have you ever had an aircraft accident? (If yes, give details in Remarks Section) Yes No 
5. I agree to take a check ride with the Club's Safety Officer or designee at my expense. Yes No 
6. I agree to abide by all F.A.A. regulations and Club Bylaws and to keep the club posted on Medical Certificate expiration date and Flight Review date.   Yes No 

Remarks:

          

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Coastal Fliers, Inc.
Revised: October 03, 2007