Membership Application

Chapter 1358 Membership Application / Renewal

To renew/apply for membership please complete all questions.
Date *

Month Day Year
Date
NOTE: You must be a member of EAA National prior to becoming an EAA Chapter 1358 member.
Are you a member of EAA National? *

Yes No
EAA National Number *
Name (As listed with EAA National) *

First Name Last Name
Nickname / Go By
Spouse
First Name
Gender

Male Female
Address *

Street Address

Street Address Line 2

City State

Zip Code
Birthday *

Month Day Year
Date
E-mail *
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Business or Occupation *
Chapter 1358 Roster Management Privacy Setting (May choose more than one) *

Set all to "Public" Set all to "Private" Set Address to "Private" Set E-mail to "Private" Set Home Phone to "Private" Set Cell Phone to "Private"
Do you have an FAA pilot's certificate? *

Yes No
Certificate Type

Student Pilot Sport Pilot Recreational Pilot Private Pilot Commercial Pilot Instructor Airline Transport Pilot
Additional Certification Ratings
Do you own an aircraft? *

Yes No
Aircraft Make & Model
Current or past aircraft projects?

Yes No
Aircraft Project Description
Are you interested in participating in our Young Eagles program?

Yes No
Young Eagles participation type

Pilot Volunteer
Are you interested in participating in our Eagle Flight program?

Yes No
Eagle Flight participation type

Pilot Volunteer
Are you interested in participating in the IMC and/or VMC clubs?

IMC VMC
Areas of Interests

Homebuilts Classics Warbirds Ultralights Aerobatic General
Please use this area to express your thoughts and suggestions for club activities, your interest in holding office, chairing a committee or volunteering as needed:
Terms and Conditions *
Payment Type

Free Student Membership (must be 18 years old or younger) Cash/Check (Bring to next meeting) Credit Card

My Products

Chapter 1358 Annual Dues $ 26.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Please verify that you are human *
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Chapter 1358 Membership Application / Renewal