Please Print

NAME: ______________________________________________________________________

SOC. SEC. NO. ________________________

ADDRESS: ___________________________________________________________________

_________________________________________________________

AGE: ______ DATE OF BIRTH: _________________ BIRTH PLACE: ________________________

HOME TELEPHONE: ______________________ BUSINESS TELEPHONE: ____________________

SPOUSE’S NAME: ___________________________________ NO. OF CHILDREN: ______________

TYPE & DATE OF LAST MEDICAL: _____________________ DATE OF LAST BFR: ___________

PILOT CERTIFICATE HELD: _________ NO.: _____________ TOTAL HOURS LOGGED _______

RATING OTHER THAN SINGLE ENGINE LAND: __________________________________

AIRCRAFT TYPE: __________________________________Hrs. _______________________

__________________________________Hrs. _______________________

__________________________________Hrs. _______________________

__________________________________Hrs. _______________________

DATE OF LAST CROSS COUNTRY OVER 250 MILES: _____________________________________

IF YOU HAVE HAD FLIGHT TRAINING WITHIN THE PAST FIVE YEARS:

Type of training: _______________________________________________________________

Name of Instructors: ______________________ LOCATION: __________________________

______________________ __________________________

Hours Dual Instruction: _______________Total ________________________Last 24 Months

HAVE YOU EVER BELONGED TO OTHER FLYING CLUBS? ________YES ________NO

Name: _____________________________ Address: __________________________________

Name: _____________________________ Address: __________________________________

HAVE YOU EVER HAD A REPORTABLE AIRCRAFT ACCIDENT? _________YES _________NO

HAVE YOU HAD A DRUG OR ALCOHOL RELATED ARREST OR CONVICTION? _______YES ______NO

FOR WHAT PURPOSE DO YOU PLAN TO USE THE CLUB AIRCRAFT? _____________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

PLACE OF EMPLOYMENT: ___________________________________________________________________

name

___________________________________________________________________

address

HOW LONG WITH PRESENT EMPLOYER: __________________

HOW LONG AT PRESENT HOME ADDRESS: ________________

PREVIOUS EMPLOYER: (If less than 2 years on present job) _________________________________________

____________________________________________________________________________________________

NAME OF BANK: ______________________________ CITY: ______________________________________

PERSONAL REFERENCES WITHIN THE CLUB: __________________________________________________

__________________________________________________

NAME OF TWO PLACES WHERE YOUR CREDIT IS ESTABLISHED:

Name: ______________________________ Address: ________________________________________

Name: ______________________________ Address: ________________________________________

NAME OF TWO PERSONAL REFERENCES:

Name: ______________________________ Address: ________________________________________

Name: ______________________________ Address: ________________________________________

I DO HEREBY AGREE TO ABIDE BY THE CURRENT BY-LAWS AND OTHER RULES AND REGULATIONS OF THE TWIN FALLS FLYERS FLYING CLUB.

DATE: ___________________ SIGNATURE: _____________________________________________________