New Membership Application

Chapter 1358 Membership Application

To apply for membership please complete all questions.
Date*

MonthDayYear
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?*

YesNo
EAA National Number*
Name (As listed with EAA National)*

First NameLast Name
Nickname / Go By
Spouse
First Name
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Birthday*

MonthDayYear
Date
E-mail*
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone 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?*

YesNo
Certificate Type

Student PilotSport PilotRecreational PilotPrivate PilotCommercial PilotInstructorAirline Transport PilotOther
Additional Certification Ratings
Do you own an aircraft?*

YesNo
Aircraft Make & Model
Current or past aircraft projects?

YesNo
Aircraft Project Description
Are you interested in participating in our Young Eagles program?

YesNo
Young Eagles participation type

PilotVolunteer
Are you interested in participating in our Eagle Flight program?

YesNo
Eagle Flight participation type

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

IMCVMC
Areas of Interests

HomebuiltsClassicsWarbirdsUltralightsAerobaticGeneralOther
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

Please verify that you are human*
Should be Empty:

Chapter 1358 Membership Application

Credit Card