Aero Care Flying Club

Membership Application

Date: ______________________________ , 2009

Applicant Name: ____________________________________________

Address: __________________________________________________

City/State/ZIP: _____________________________________________

Telephone: ____________________ Day ____________________ Night

Date of Birth ____________ / ____________ / ____________

Marital Status: Single __________ Married __________ Divorced __________ Widow(er) _________

Flight Experience: __________________________________________________________________

Licence(s) Held: ___________________________________________________________________

FAA Medical: Class I ____ Class II ____ Class III ____ Student ____ Expiration: ________________

Spouse's Name: ____________________________________________

Date of Birth ____________ / ____________ / ____________

Dependent Children:

Name: ________________________________ Birthdate __________ / __________ / __________

Name: ________________________________ Birthdate __________ / __________ / __________

Name: ________________________________ Birthdate __________ / __________ / __________

Name: ________________________________ Birthdate __________ / __________ / __________

Applicant Signature: _______________________________________________________________

Mail Form to: