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Please complete all of the applicable blanks below. Dues for new members are pro-rated the first year you join based on the number of months left in the current year. Annual dues for regular members are $18.00 and must be paid NLT the February meeting of the current year.

NAME SPOUSE NAME

ADDRESS CITY

STATE ZIP+4 HOME PHONE

BUSINESS PHONE CELL FAX

E-MAIL EAA#

Do you have a particular area of interest or Hobby: (USE BACK IF NECESSARY)

Type of employment (optional)—Retired, Student, etc.

Previous employment aviation related:

Military experience:

Would you be willing to present a program? Yes Topic

Would you be interested in serving on a committee? Yes Committee

Would you serve as a chapter officer? Yes:

Aircraft currently building: Status:

Aircraft currently restoring: Status:

Aircraft you have built or restored in the past:

Future project:

Aircraft you own: Aircraft you fly:

Pilot certificates: (CIRCLE LETTERS) A – Private B – Commercial C – Instruments

D – Multi-engine E – ATP F – Seaplane G – Helicopter H – CFI I – CFI-I J – Ultralight

K – Student L – Ready to start M - Glider

Aircraft Maintenance Skills: (CIRCLE NUMBERS) 1 – A&P 2 – IA 3 – Sheet Metal

4 – Dope & Fabric 5 – Composites 6 – Welding 7 – Wood 8 – Electrical 9 – Engine maintenance

10 – Avionics 11 – Auto Engines

Other Talents:

Additional Comments (use back if necessary):

Most interesting/unusual aircraft you’ve been associated with (use back if necessary):

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