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MPC Member App

This membership application collects personal and professional information from an applicant to the Mishawaka Pilots Club. It requests details like name, contact information, pilot certifications, flight experience, employer information, references, and payment details. The applicant signs to authorize background checks and agrees to pay fees including initiation fees, maintenance fees, dues, and a fuel deposit if their application is approved.

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dee6665
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© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
123 views

MPC Member App

This membership application collects personal and professional information from an applicant to the Mishawaka Pilots Club. It requests details like name, contact information, pilot certifications, flight experience, employer information, references, and payment details. The applicant signs to authorize background checks and agrees to pay fees including initiation fees, maintenance fees, dues, and a fuel deposit if their application is approved.

Uploaded by

dee6665
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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Account Number_____________ Reading of Application _____/_____/_____

Pin Number _____________

Mishawaka Pilots Club


Membership Application

Name:_______________________________ Phone Number:_____________________


Address:_____________________________ Social Security:____________________
City/State/Zip ____________________________

Drivers License Number:___________________ Date of Birth: _____/_____/_____


Pilots Certificate Number: __________________ Date of Issue: _____/_____/_____
Medical Date: _____/_____/_____ Medical Class: ___________
BFR: Date: _____/_____/_____ Email: _______________________
Ratings: ____________________________________ Total Hours: ______________

Sponsor: ____________________________________ Insurance Carrier: _____________________


I plan on Joining MAA_______ VFR___________ None_________
If you own your own Airplane List Make/Model/N#
__________________________________________
Please List any Accidents, Incidents, or Violations: __________________________________________
____________________________________________________________________________________
Please list any Drug, Alcohol or Felony Convictions:
__________________________________________

Present Employer: _____________________________ Phone Number: ________________


Address: __________________________________ Position:____________________________
___________________________________ Years of Service: ____________________
Release: By signing this application, I give permission to the Membership Committee to check
FAA records, Law Enforcement Agencies records and credit and/personal references
to ensure eligibility for membership.

Date Submitted _____/_____/_____ Initiation Fee $__________ Date


_____/_____/_____
Date Approved _____/_____/_____ Maintenance Fee $__________ Date _____/_____/_____
Date of Membership _____/_____/_____ Dues $ _________ Date
_____/_____/_____
Fuel Deposit $ _________ Date
_____/_____/_____
Total Due $ _________

Signature of Officer __________________________________________ Date _____/_____/_____


Account Number_____________ Reading of Application _____/_____/_____
Pin Number _____________

Signature _________________________________ Date of Application _____/_____/_____

Please Complete the information on the other side

Credit References
Please Include Phone Number and Type of Credit
1. ________________________________________________________________________________
_________________________________________________________________________________
2. _________________________________________________________________________________
_________________________________________________________________________________
3. _________________________________________________________________________________
__________________________________________________________________________________

Name of Bank _________________________________________

Personal References
Please include Phone Number and Relationship
1. ________________________________________________________________________________
_________________________________________________________________________________
2. _________________________________________________________________________________
_________________________________________________________________________________
3. _________________________________________________________________________________
__________________________________________________________________________________

Date Submitted _____/_____/_____ Initiation Fee $__________ Date


_____/_____/_____
Date Approved _____/_____/_____ Maintenance Fee $__________ Date _____/_____/_____
Date of Membership _____/_____/_____ Dues $ _________ Date
_____/_____/_____
Fuel Deposit $ _________ Date
_____/_____/_____
Total Due $ _________

Signature of Officer __________________________________________ Date _____/_____/_____


Account Number_____________ Reading of Application _____/_____/_____
Pin Number _____________

How did you learn of Mishawaka Pilots Club _______________________________________________

Date Submitted _____/_____/_____ Initiation Fee $__________ Date


_____/_____/_____
Date Approved _____/_____/_____ Maintenance Fee $__________ Date _____/_____/_____
Date of Membership _____/_____/_____ Dues $ _________ Date
_____/_____/_____
Fuel Deposit $ _________ Date
_____/_____/_____
Total Due $ _________

Signature of Officer __________________________________________ Date _____/_____/_____

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