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 (Bryan Stone-Pres: 360-308-9092)

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

7:30 PM Bremerton National Airport-Civil Air Patrol Building #100; Enter airport and take first left. It is the last building you

will come to and the only one on the left side of the street.

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