Warren Aviation Club, Inc.

Membership Application



Name__________________________________________________ Birth Date ___________________


Address ____________________________________________________________________________


City ________________________________________ State ______________ Zip _________________


Home Phone __________________________  Driver’s License State and Number _________________


Email ________________________________________


Employer & Occupation _______________________________________________________________


Credit References (3) __________________________________________________________________





Sponsor (Current Club Member) _________________________________________________________


Pilot Certificate & Rating Held __________________________________________________________


Medical Class & Date _______________________________  Hours Flying Time _________________


Ground School _______________________________________________________________________


Type Aircraft Flown & Where ___________________________________________________________




The following questions are required information, which is prerequisite to obtaining insurance coverage with the club’s insurance carrier.


Have you at any time:

1.                  Had any aircraft accidents, incidents or claims; or had your certificate

surrendered, suspended or revoked?                                                           Yes (  )    No (  )


2.         Had an automobile driver’s license surrendered, suspended or revoked?       Yes (  )    No (  )


3.         Been arrested for, or charged with, operating a motor vehicle or aircraft  

            under the influence of alcohol or drugs?                                                         Yes (  )    No (  )


4.         Been convicted of, or plead guilty or no-contest to a felony crime or                                                                        

            misdemeanor other than traffic violation?                                                        Yes  (  )  No  (  )


5.         Had an insurance company cancel or decline to insure or refuse to                                                                          

            renew aircraft insurance?                                                                                Yes  (  )  No  (  )


If you checked YES to any of the above mentioned questions, please explain below:






I have read the By Laws, General Operating Rules and the Schedule of Fees and Rates of the Warren Aviation Club, Inc. and do hereby agree that I will accept conditions and assume responsibilities as set forth in said By Laws, General Operating Rules and Schedule of Fees and Rates.


Signature __________________________________________________  Date ____________________




Club Use


Accepted Date ____________________________  Rejected Date ______________________________


Placed on waiting list date ___________________________


Comments: _______________________________________________________________________