| Forms for the Silver City Flying Club |
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Silver City Flying Club
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Application For Membership
Applicants Name:___________________________________________________________________
Address: ______________________________________Home Phone:
City: ___________________________________________Cell Phone:________________________
State:_________________________ Zip:_____________Work Phone:_______________________
Do you own or rent the above address? Own_______ Rent_______Other____________
Date of Birth:_________________________________ E-Mail Address:_____________________
Occupation:_________________________________________________________________________
Employer:___________________________________________________________________________
Address:____________________________________________________________________________
City:___________________________________State:___________________Zip:________________
(If self-employed,please list business name & address)
______________________________________________________________________________________
Number of years with the above employer or in business:________________________
FAA License no:__________________________ Date of Last BFR:______________________
BFR Conducted by:_________________________________________________________________
Date of last FAA physical:________________ Conducted by:_________________________
Please indicate Medical Class: I_______ II________ III_______
List Ratings held:___________________________________________________________________
List total hours to date:_______________
Total hours in type: C-152_______ C-172_______Piper Warrior_______Archer________
Hours in other types:_______________________________________________________________
Are you 90 day current? Yes____ No____ Date last flown:________________________
Are you night current? Yes_____ No______ Date last flown:________________________
Total hours at night:_____________ Night hours in type:_____________________________
Please answer the following questions
If you answer “yes” to any of the following questions, please explain.
1. Do you have any physical limitations, waivers and/or conditions on your medical certificate or pilot certificate?
Yes_______ No_______
Explanation__________________________________________________________________________________
2. Have you ever been cited for any violation of FAA Regulations? Yes___ No___
Explanation__________________________________________________________________________________
3. Have you ever been involved in an aircraft accident or incident? Yes__ No___
Explanation__________________________________________________________________________________
4. Have you ever been arrested for or pleaded guilty to driving any vehicle while intoxicated? Yes____ No____
Explanation__________________________________________________________________________________
5. Have you ever been treated for substance abuse? Yes____ No____
Explanation__________________________________________________________________________________
6. How did you hear about the Silver City Flying Club?_____________________________________
The Silver City Flying Club reserves the right to accept or reject this application based upon recommendations from
the membership.
Purchase share of:___________________________________________________________________________
Applicants Signature________________________________ Date:__________________________________
Rev: 8/16/05
Applicants Name:___________________________________________________________________
Address: ______________________________________Home Phone:
City: ___________________________________________Cell Phone:________________________
State:_________________________ Zip:_____________Work Phone:_______________________
Do you own or rent the above address? Own_______ Rent_______Other____________
Date of Birth:_________________________________ E-Mail Address:_____________________
Occupation:_________________________________________________________________________
Employer:___________________________________________________________________________
Address:____________________________________________________________________________
City:___________________________________State:___________________Zip:________________
(If self-employed,please list business name & address)
______________________________________________________________________________________
Number of years with the above employer or in business:________________________
FAA License no:__________________________ Date of Last BFR:______________________
BFR Conducted by:_________________________________________________________________
Date of last FAA physical:________________ Conducted by:_________________________
Please indicate Medical Class: I_______ II________ III_______
List Ratings held:___________________________________________________________________
List total hours to date:_______________
Total hours in type: C-152_______ C-172_______Piper Warrior_______Archer________
Hours in other types:_______________________________________________________________
Are you 90 day current? Yes____ No____ Date last flown:________________________
Are you night current? Yes_____ No______ Date last flown:________________________
Total hours at night:_____________ Night hours in type:_____________________________
Please answer the following questions
If you answer “yes” to any of the following questions, please explain.
1. Do you have any physical limitations, waivers and/or conditions on your medical certificate or pilot certificate?
Yes_______ No_______
Explanation__________________________________________________________________________________
2. Have you ever been cited for any violation of FAA Regulations? Yes___ No___
Explanation__________________________________________________________________________________
3. Have you ever been involved in an aircraft accident or incident? Yes__ No___
Explanation__________________________________________________________________________________
4. Have you ever been arrested for or pleaded guilty to driving any vehicle while intoxicated? Yes____ No____
Explanation__________________________________________________________________________________
5. Have you ever been treated for substance abuse? Yes____ No____
Explanation__________________________________________________________________________________
6. How did you hear about the Silver City Flying Club?_____________________________________
The Silver City Flying Club reserves the right to accept or reject this application based upon recommendations from
the membership.
Purchase share of:___________________________________________________________________________
Applicants Signature________________________________ Date:__________________________________
Rev: 8/16/05