Club Application Form.

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

Pilot Experience

Total Time: Pilot in Command Time: Time flown last 12 months:
C-172 Time: Arrow IV Time: RV-7A Time:
Complex/Retract Time:

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?

Have you ever been involved in any aircraft accident or incident?

Do you have any physical impairments, waivers or statement of demonstrated ability (other than corrective lenses), limitations or conditions attached to your medical certificate?

Please explain any "yes" resposnses to the above 4 questions:

Tell us about the type of flying you plan on doing in the club aircraft

Tell us about any skills or experience that you have that would benefit the club:

What is your ability/willingness to participate in club duties, including eventually holding office?

Are you financially willing/able to join the club now or are you considering membership at a future date?

A member of the club will contact you to provide more information and answer questions. If you prefer to receive additional information via email, please feel free to provide questions here: