MEMBERSHIP APPLICATION

 Date of Application
Applicant Information
Last name First name Middle
Street City State Zip
Home phone Work phone Cell phone Fax phone
Date of birth Eye color Male o Female o Height Weight Married o Single o
Occupation
Employer
Emergency Information
Name of person to notify in case of emergency Phone
Street City State Zip
Education (check those completed)

Elementary o High School o College o Trade o Other o

Hobbies and special interests:
Military Service

Active o Retired o Reserve o

Army o Navy o Air Force o Coast Guard o Marines o Other o

Pilot’s License

Have license?  Yeso  Noo

 Type Number Total time as PIC Date of last BFR

Aircraft Model

Approximate Hours

Date of Last Flight
     
Other relevant experience:
 

Mail completed application to: KAS /PO Box 5631, Bremerton, WA 98312 (206-842-2986)

Initiation fee: $600.00, Monthly Dues: $72.00 --Join us on the first Wednesday of every month

7:30 PM at the Bremerton airport terminal bldg.

Medical Certificate

Have medical? Yeso Noo

 Class Date Number Examiner’s S/N
Disease, disability, handicaps, limitations (If YES, please explain below): Yes o No o
 
References
Personal Phone
KAS Member Phone
Flight Instructor Phone
Other Phone
Are you willing to serve as a club officer if appointed, elected or volunteer? Yes o No o
Have you ever been arrested? (If YES, please explain below): Yes o No o
Applicant’s Signature Date
Office use only
Date of Board
 Option offered

Accepted: Yes o No oYes
Other action needed:
President’s Signature Date