MEMBERSHIP APPLICATION

To apply for membership, print this page, complete the application and mail it to MFC,
P.O. Box 25421, Chattanooga, Tennessee 37422-5421.

To be considered by MFC's Board of Directors, this application must be accompanied by photocopies of your medical certificate and the logbook entry for either your last check-ride approval for rating or last biennial flight review, whichever is most current.

Name: __________________________________________ Spouse: _______________

Address: ________________________________________________________________

City/State/Zip: ___________________________________________________________

Email Address: ___________________________________________________________

Phone (Home/Business/Fax or Cell):______________/______________/_____________

Birthday: ______________ BFR Date: _____________ Medical Date: ______________

Occupation: ___________________________ Company: _________________________

Driver's License #/State: ___________________________________________________

Airman Certificate #: ______________________________________________________

Ratings: Student _____ Private _____ VFR _____ IFR _____ ATP _____ CFI _______

CFII _____ Commercial _____ Single Engine _____ Multi Engine __________

Total hours logged: _________________ IFR hours: __________________

Total hours in: 172 _____ Cherokee _____ 182 _____ All High Performance ______

Largest aircraft qualified in: ___________________ Hours flown:________

Do you understand that you must meet the following requirements in order to fly the Club's 182 and be covered by the Club's insurance policy?

• 10 hours in type if you have less than 100 hours of total logged flight time
• 5 hours in type if you have 100 hours or more of total logged flight time
• have a written sign-off from a Club approved instructor

Yes_________ No__________

Your last CFI's name/phone: _________________________________/______________

Your last FBO Aircraft rental/phone: ___________________________/______________

Personal references (including MFC members):

Name/phone: ______________________________________________/______________

Name/phone: ______________________________________________/______________

Name/phone: ______________________________________________/______________

In the past 12 months, have you:

(a) Had an accident, incident, or any unreported claim? Yes _____ No ______

(b) Had your pilot's license or driver's license suspended or revoked? Yes ___ No ___

(c) Been arrested or charged with operating either a motor vehicle or aircraft while under the influence of drugs or alcohol? Yes _____ No _____ (Please explain any "YES" answers to the above three questions on the reverse side of this application.)

Have you read the MFC's By-Laws and Rules and Regulations? Yes _____ No ______

Do you agree to abide by the MFC's By-Laws and Rules and Regulations?
Yes _____ No ______

I warrant that all of my answers are true and complete to the best of my knowledge and belief. No material information has been withheld and I hereby authorize MFC to investigate all statements contained herein.

Signature: _______________________________________ Date: _________________