HILL FLYING CLUB INC
EVV Pilots Club, Inc.20 N.W. 3rd Street14th FloorEvansville, IN 47708APPLICATION FOR MEMBERSHIPNAME: FORMTEXT ?????Deposit Class ($): FORMTEXT ????? WORK PHONE: FORMTEXT ????? CELL PHONE: FORMTEXT ?????ADDRESS: FORMTEXT ?????CITY: FORMTEXT ?????STATE: FORMTEXT ?????ZIP: FORMTEXT ????? EMAIL ADDRESS: FORMTEXT ?????IN CASE OF EMERGENCY NOTIFY:NAME: FORMTEXT ?????PHONE NUMBERS: FORMTEXT ?????ADDRESS: FORMTEXT ?????RELATIONSHIP: FORMTEXT ?????PILOT CERTIFICATE #: FORMTEXT ?????TYPE: FORMTEXT ?????DATE ISSUED: FORMTEXT ?????RATINGS: FORMTEXT ?????BIRTH DATE: FORMTEXT ?????DRIVER LICENSE #: FORMTEXT ?????ISSUING STATE: FORMTEXT ?????DATE OF MEDICAL CERTIFICATE: FORMTEXT ????? CLASS: FORMTEXT ?????LIMITATIONS: FORMTEXT ?????DATE OF LAST FLIGHT REVIEW OR OTHER QUALIFYING EVENT: FORMTEXT ?????EMPLOYER: FORMTEXT ?????OCCUPATION: FORMTEXT ?????AOPA MEMBER: FORMTEXT ?????WINGS PROGRAM Participant: FORMTEXT ?????AIRCRAFT TYPETOTAL HOURSLAST 90 DAYSLAST 6 MONTHSLAST 12 MONTHSNIGHT Last 6 MonthsIFR, Last 6 MonthsSEL Fixed gearHigh Performance FORMTEXT ????? FORMTEXT ?????MEL FORMTEXT ????? FORMTEXT ?????OTHERTOTAL FLIGHT TIME FORMTEXT ????? FORMTEXT ?????HAVE YOU EVER HAD YOUR PILOTS LICENSE REVOKED OR SUSPENDED? FORMTEXT ?????HAVE YOU EVER BEEN INVOLVED IN AN AIRCRAFT ACCIDENT OR INCIDENT? FORMTEXT ?????HAVE YOU EVER BEEN CITED FOR A FAR VIOLATION? FORMTEXT ?????*IF YES TO ANY OF THE ABOVE, EXPLAIN BELOW, OR REVERSE SIDE..I certify that the above information is true and correct to the best of my knowledge and that willful omission or inaccuracies are grounds for expulsion from the Club. I have read, understand and agree to abide by all current articles and sections of club by-laws, club operating rules, and FARs. If any accident is caused through violation of FARs or local regulations, the member at fault shall be responsible for the uninsured portion of the damages. Any member is liable to the corporation for any damage resulting from his own carelessness and negligence. I will maintain my account on a current basis and agree to pay reasonable fees if collection action becomes necessary. I understand that any of the information contained herein may be used in the process of obtaining insurance; otherwise it will be kept confidential.SIGNATURE: ____________________________________________________ DATE FORMTEXT ?????IMPORTANT: PLEASE ATTACH A COMPLETED CREDIT CARD AUTHORIZATION FORM WITH THIS APPLICATION. ................
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