This form needs to be completed by all active members.

This information is for our insurance renewal and must be done promptly and accurately. In addition, we need photocopies of the last page in your log book, medical certificate, and license. Please send this form and photocopies with your February payment. Failure to provide the club with the above information will result in the immediate removal from the flying roster.

Name: ______________________________Date: ____________________

Local Address: _______________________________________________

Permanent Address: ___________________________________________

Local Phone #: ______________ Business Phone #: ______________

College: ____________________ Department or Major: ___________

Status: _____ Undergrad.(yr. of grad._____) _____ Grad.student

_____ Faculty or Staff

Age: __________ Type License:_________________________________

License #: ___________________________________________________

Ratings: _____________________________________________________

Hours in Cessna 152: ____________________

Hours in Warrior: _______________________

Conventional Gear Hours: ________________

Retractable Gear Hours: _________________

Multi-engine Hours: _____________________

Total Hours: ____________________________

Have you ever been involved in an aircraft accident, have you ever had your license suspended or have you been convicted of any motor vehicle (other than parking) or drug-related offences? __________

If yes, please explain on back and list dates and nature of incident.

When was your last annual check ride(bi-annual if you have more than 400 hours or an instrument rating)? ____________________

Class medical certificate: __________Date:__________

I hereby certify that all the above information is factual.

Signature: _________________________ Date:____________________