MEMBERSHIP APPLICATION APPLICANT INFORMATION

FULL NAME*

DATE OF BIRTH*

Date

STREET*

EMAIL*

example@example.com

CITY*

STATE*

ZIP

EMPLOYER*

POSITION*

DATE EMPLOYED*

Date

HOME PHONE

CELL PHONE*

CITIZENSHIP*

CERTIFICATES*

RATINGS*

ENDORSEMENTS*

COMPLEXTAILWHEELHIGH PERFORMANCEOTHER

AIRMAN’S CERTIFICATE NUMBER*

DATE ISSUED*

Date

FLIGHT EXPERIENCE*

	TOTAL TIME	LAST 90 DAYS	LAST 12 MONTHS
SINGLE ENGINE LAND
SINGLE ENGINE SEA
PIPER PA28-180
MOONEY M20F
INSTRUMENT (ACTUAL)
INSTRUMENT (HOOD)
TAILWHEEL
RETRACTABLE GEAR
MULTI-ENGINE
TURBOPROP
JET
ROTORCRAFT
INSTRUCTOR

CURRENCY DETAILS*

DATE OF LAST FLIGHT REVIEW*

Date

DATE OF LAST MEDICAL*

Date

CLASS OF MEDICAL*

RESTRICTIONS E.G. LENSES, NO NIGHT FLIGHT, etc*

HAVE YOU EVER HAD A VIOLATION OR ACTION AGAINST YOUR PILOT CERTIFICATE? *

YESNO

EXPLAIN IN DETAIL

HAVE YOU EVER BEEN INVOLVED IN AN ACCIDENT OR INCIDENT INVOLVING AIRCRAFT, REPORTED OR NOT?*

YESNO

EXPLAIN IN DETAIL

HAS YOUR DRIVERS LICENSE EVER BEEN SUSPENDED OR REVOKED?*

YESNO

EXPLAIN IN DETAIL

HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OR ARE YOU UNDER INVESTIGATION FOR ANY CRIME?*

YESNO

EXPLAIN IN DETAIL

HAVE YOU EVER BEEN CONVICTED OF ANY DRUG RELATED ACTIVITIES, INCLUDING DUI?*

YESNO

EXPLAIN IN DETAIL

HAVE YOU HAD ANY ROAD ACCIDENTS IN THE PAST 5 YEARS?*

YESNO

EXPLAIN IN DETAIL

HAVE YOU EVER BEEN DENIED INSURANCE OF ANY KIND?*

YESNO

EXPLAIN IN DETAIL

HAVE YOU EVER FILED AN AVIATION INSURANCE CLAIM?*

YESNO

EXPLAIN IN DETAIL

HAVE YOU EVER BEEN CITED FOR VIOLATING CIVIL OR MILITARY FLIGHT REGULATIONS?*

YESNO

EXPLAIN IN DETAIL

HAVE YOU EVER BEEN A MEMBER OF A FLYING CLUB?*

YESNO

PROVIDE CLUB NAME AND CONTACT INFORMATION

HOW DID YOU HEAR ABOUT US?*

WHO REFERRED YOU?

OTHER:

NAME*

RELATIONSHIP*

PHONE NUMBER*

I have read and understood the bylaws and operating rules. I agree to abide by all rules, regulations and procedures of the club, the FAA, and all other agencies. I agree to sign and abide by the waiver and release agreement.

I agree that I will not use club aircraft for any commercial, business, or illegal activities.

I agree to pay all assessed dues and fees as required by the club bylaws and other rules and regulations and understand that failure to do so will result in loss of club privileges and potential termination of membership.

I understand that if I am found liable for damages to club aircraft or equipment due to negligence, I will be held responsible for the insurance deductible and other costs associated with the claim resulting from that damage.

I hereby authorize Mission Aviation to electronically debit the checking, savings, or credit card account I provide on behalf of Indy Aviators Flight Club for all fees pursuant to the club bylaws. This authorization will continue until revoked in writing. I understand that if the debit is returned unpaid due to insufficient funds or my banks electronic draft restrictions, I may be charged a $35 NSF penalty for the returned item.

SIGNATURE OF ACKNOWLDEGEMENT AND ACCEPTANCE

DATE*

Date

NAME

RELATIONSHIP

SIGNATURE

DATE

Date

MEMBERSHIP APPLICATION

EMERGENCY CONTACT

ACKNOWLEDGMENTS

APPLICANTS UNDER 18 YEARS OF AGE MUST HAVE PARENT OR GUARDIAN APPROVAL