First Last

Address

Street Address

City

State

Zip Code

Email Address:

Cell Number:

Home Number:

Work Number:

Employer:

Date of Birth

Pilot Type: Student Private Commercial Commercial / CFI ATP

Approximate Number of Hours:

Do you have a medical certificate: Yes No

Reference 1 Name and Phone number:

Reference 2 Name and Phone number:

I am familiar with the By-Laws of The Flying 64th, Inc. and I agree to abide by them if elected to membership: