St Louis Flying Club

Club Application Form.

Name (reqd): Birth Date:
Street Address (reqd):
Additional Address:
City (reqd): State (reqd): Zip Code (reqd):
Phone (Work):(Home):
E-Mail Address (reqd):

License Type:

Airman Certificate Number:

Ratings Held (Check all that apply):

CFI CFII A&P AI

Medical Certificate:

Bienniel Flight Review Date:
Total Time: In last year: Total in C-172:

Have you ever had your pilots license surrendered, suspended or revoked; or been arrested or charged with operating an aircraft or motor vehicle under the influence of drugs or alcohol?

Have you ever been convicted or, or plead guilty or no contest, to any felony or misdemeanor?

Please explain any "yes" reposnses to the above questions, and write a brief statement requarding why the current club members would benefit from having you as a member.

(Thank you for your application)