Join the club

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Own or Rent the above address? *

Own

Rent/Lease

Mobile Phone *

(###)

###

####

Home

(###)

###

####

Work Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Self Employed? *

Yes

No

Certificates & Ratings *

Check all that apply

Sport/Recreational Pilot

Private

Commercial

ATP

CFI

CFII

IFR Rated

ATC

A&P

Other

Last BFR *

MM

DD

YYYY

Instructor Name *

First Name

Last Name

Basic Med/Medical Class Expiration *

MM

DD

YYYY

Q1: Do you have any physical limitations, waivers and/or conditions on your pilots or medical certificates? *

No

Yes, please explain below:

Q2: Have you ever been cited for any violation of FAA Regulations? *

No

Yes, Please explain below:

Q3: Have you ever been involved in an aircraft incident, accident or unreported claim? *

No

Yes, please explain below:

Q4: Within the last 12 months, have you had your pilot or drivers license suspended or revoked; or have you been arrested for or charged with operating an aircraft or motor vehicle while under the influence of drugs or alcohol? *

No

Yes, Please explain below:

Q5: Have you been treated for substance abuse? *

No

Yes, optional to explain below:

Q6: Have you ever been convicted of, plead guilty to, or no contest to any felony? *

No

Yes, optional to explain below:

Reference 1 *

Optional - Club Member, Instructor, other Pilot

First Name

Last Name

Reference 1 Phone *

(###)

###

####

Reference 2

Optional

First Name

Last Name

I hear by acknowledge that I have read and agree to abide by the By-Laws and Operating Rules of the Connecticut Flyers, and agree to pay all costs and attorneys fees incurred by the Club to enforce the rules. Upon acceptance, CT Flyers requires copies of my license, medical certificate, and log book endorsement of last biennial or rating earned, and a check in the amount made out to Connecticut Flyers. I understand that enrollment in the club will require a monthly financial commitment, which may vary from time to time. *

POLICY STATEMENT TO POTENTIAL NEW MEMBERS: Any applicant to the Connecticut Flyers will be required to submit an application together with a check in the amount of the share purchase price. The share purchase price amount will be held in escrow by the club pending the acceptance of the application. Before acceptance, the applicant will be required to fly with an instructor of the Board's choosing to determine the applicant's suitability for club membership.

Accept

Do NOT Accept

Digital Signature *

First Name

Last Name

Signed Date *

MM

DD

YYYY