Cloud One Flying Club INC.

Membership Application

Name: Last: First: Middle:

Address:

City, State, ZIP:

Home Phone: Work Phone:

E-Mail Home: E-Mail Work:

Employer: Occupation:

Employer’s Address:

Emergency Contact: Name: Phone:

Date of last FAA physical exam: Class: Doctor:

Accident History? Yes / No (If yes, explain)

Ever had disciplinary action from FAA?: Yes / No (If yes, explain)

Date of Birth:

Has applicant ever been arrested for DWI, DUI, C&I or any drug related offense? (If yes, explain)

Drivers Licenses Number and State

CERTIFICATE: (please indicate current pilot certificates and ratings)

Certificate Number: _ _ _ _ _ _ _ _ _

Student______ Private______ Commercial ______ ATP ______

Multi-Engine ______ Instrument ______ Sea ______ Flight Instructor ______

EXPERIENCE: (please indicate your flight times.)

Total time- Single Engine ______ Total time- Multi-engine ______

Total time- Retract ______ Total time- Instrument ______

Total time –Cessna ______ Total time - _______

Total time – Cherokee ______ Date of last BFR: __________

Expected flying hours per month: ________

REASON CLOUD ONE APPEALS TO ME: (Business, pleasure, cross-country, cost, etc…)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I believe that the information submitted is true to the best of my knowledge and may be used to determine acceptance into Cloud One Flying Club. By completing this form, I hereby authorize credit information and Driving records for myself to be released to the Cloud One Flying Club, Inc.

Signature:_______________________________ Date: _________________