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 ____________________
Placed on waiting list date ___________________________
Comments: _______________________________________________________________________