ARCTIC FLYING CLUB, INC.

Fairbanks, Alaska

Membership Application

Word copy

   Name:   __________________________________________________

            Mailing Address:  _________________________________________

                                        __________________________________________

            email: ___________________ Home phone:  ___________________

            Work phone: _____________ Cell phone:  _____________________

            Age (needed for insurance purposes):  ___________________

             Employer:  ____________________________________________________

     Occupation:  __________________________________________________

    Personal references (local people, excluding relatives, who can vouch for your good character):

     Name:  _____________________      Name:  _____________________

      Home phone: ________________       Home phone:  _______________

      Work phone:  ________________      Work phone:  ________________

Aviation references (people who can vouch for your skills as a pilot, if  applicable):

      Name:  _____________________      Name:  _____________________

      Home phone: ________________       Home phone:  _______________

       Work phone:  ________________      Work phone:  ________________

Aviation experience:

       License (Student, Private, etc.) and issuance date*:  ___________

       Ratings (SEL, etc.):  __________________

        Total Hours:  ______  Hours in a 172:  ______

        Conventional (Fixed) Gear Hours:  _____  Retractable Gear Hours:  _____

         Multi-engine Hours:  0 hours

          Any aviation accidents, incidents, or license administrative actions, suspensions, or civil penalties (ever)?  ________

           If “yes,” please provide:

• date, location, and cause of accident(s) and/or incident(s)______________________________________
• dollar amount of civil penalty, bodily injury, property, and/or aircraft damage; and _________________
• if applicable, length and reason for pilot certificate suspension(s)._______________________________

            Class and date of most recent medical certificate*:  __________________________           

           Date of most recent BFR, if applicable (enclose photocopy of logbook entry with  application):  _______________

            *enclose copies of license, medical certificate, and most recent log book BFR entry, as applicable, with application.

I certify that all the above statements are true and complete as of the date of my signature below, and that no information has been withheld or suppressed which might adversely affect my acceptance as a member of the Arctic Flying Club, Inc.  Furthermore, I certify that within the past 36 months:  (1) neither my pilot nor driver’s license have been surrendered, suspended, or revoked; (2) I have not been arrested or charged with operating an aircraft or other motor vehicle under the influence of drugs or alcohol; and (3) I have not been convicted of, or pleaded guilty or no contest to, any felony or misdemeanor other than parking violations.

If my membership application is accepted, I agree to abide by the Club’s Constitution, Bylaws, and Operating Rules, any of which may be amended from time to time as circumstances warrant.

Signed:  __________________________________________

Date:  ___________________

Mail your completed application and document copies (license, medical certificate, BFR log book entry, per instructions above) with a check for $255 ($200 membership plus $55 first month’s dues) to:

Arctic Flying Club

P.O. Box 72772

Fairbanks, AK 99707