Person to notify in case of an emergency: Name  Phone    Alt. Phone

F.A.A. Pilot Certificate Number    Issue Date    F.C.C. Operator License Date    Date of Last Biennial  Medical Certificate Class    Date of Last Physical  Licences and Ratings You Hold:

Please summarize your flight experience, including the make of aircraft and hours logged: Has your pilot's license ever been suspended?   Yes    No If the answer is "yes", please explain: Have you ever been involved in an aircraft accident, or an incident which required notification of the NTSB or FAA?    Yes    No If the answer is "yes", please explain: How did you learn of the Chuckanut Flying Club? Name of person, if any, who referred you for membership:   If membership in Chuckanut Flying Club is accepted, you agree to pay a non-refundable initiation fee of $350. Members of Chuckanut Flying Club bring a great degree of skill, experience, and character to the Club. Members are highly valued for these qualities and for their participation in Club activities.