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. or Fax 423.510.9971 You may also contact Lloyd Baldridge @  423-309-9084  Click here to email Lloyd

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: _________________