DAYTON PILOTS' CLUB
DAYTON WRIGHT BROTHERS AIRPORT, DAYTON, OHIO
APPLICATION FOR MEMBERSHIP

RETURN TO:	Dayton Pilot's Club
		P.O. Box 750924
		Dayton, Ohio 45475
		 
Name   _____________________________________________  Age _______________________

Street Address ___________________________________________________________________

City _____________________________ State ______________ Zip _______________________

Telephone:  Home _______________Business _______________ Emergency ________________

Employer _______________________________________________________________________

E-mail Address:__________________________       Spouse_____________________________

We want to thank you for your interest in the Dayton Pilots' Club. Applications will be accepted from students and licensed pilots. However, by making application to this club, you understand that the Dayton Pilots' Club has no obligation to accept you as a club member. If accepted, you will be subject to a mandatory 90 day minimum probationary period, during which time you will be required to take a ground and flight check with an appointed club instructor, before equipment may be used for solo or Pilot-In-Command (PIC).

With your application, please send a copy of: 1. Drivers License, 2. Pilots License, 3. Medical Certificate.  This application will be returned to you for validation by the examining instructor and returned to the secretary before final acceptance into the club.

Your performance as a pilot and your care of the club aircraft and facilities will be scrutinized by all club members.  Until final acceptance, any club trustee can request your resignation and order the return of your share value. You may, if you wish, appeal to the Board of Trustees, but may not utilize club facilities or equipment until a Board decision has been rendered.

In consideration for membership in the Dayton Pilots' Club and all the rights and privileges appurtenant thereto, I,_________________________ hereby agree to pay said club the sum of $53.50 application fee and $740.00 as my share value in the club. I understand that the share value is refundable when I leave the club. Said membership shall be subject to all rules and regulations of said club either now or hereafter made.

CERTIFICATION
I hereby certify that the entries on this form are true and correct without any mental reservation whatsoever. Furthermore, I understand that I will be subject to dismissal if anything in this application is found to be false in any particular.

	     ______________________________       ________________
	         Signature of Applicant                Date 

CERTIFICATION INFORMATION

Recommended by________________________________

Date of Birth ___________________________________  Place of Birth ___________________

Social Security Number___________________________

Present FAA Ratings ____ Student  ____Private  ____COM  ____ATP  ____CFI  ____CFII 

 ____ Instrument   ____ Multi   ____Land   ____Sea   ____ Glider  ____ Other _________

Certification Number ____________________________ Limitation_________________________ 

Medical: Class ____________________ Expires _________________ Waiver No. ____________

Total Hours _________________ Day __________ Night __________  Instrument ___________

Date of last Biennial Flight Review ________________ Instructor's Name ______________

Other sponsored members who might be flying ________________________________________

Certificate No.  _____________________________________  Medical No._________________

Have you ever had a driver's license revoked or suspended or been arrested for other than a misdemeanor? Yes_________ No _________

List any vehicular traffic accidents and/or citations in last 5 years. Include details and $ value.
None ________
______________________________________________________________________________
______________________________________________________________________________

Have you ever been a member of Alcoholics Anonymous or ever been treated for alcoholism? Yes_________ No__________

Do you now, or have you ever used, except as prescribed by a physician, cocaine or its derivatives, marijuana or other drugs? Yes ________ No _________

List any aircraft accident in which you were a crew member. Include dates, type of aircraft, extent of damage ($ value), place of accident, probable cause as determined by FAA (if any) and penalties incurred. None ________
______________________________________________________________________________
______________________________________________________________________________

List any violations of FAR's and details including penalties, None _________
__________________________________________________________________________________
__________________________________________________________________________________

To return to the Homepage, Click Here