COLLEGIATE FLYING CLUB MEMBER INFORMATION

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:____________________