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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