| Membership Application |
| EAA Chapter 651 |
| Send compleated form along with $20.00 check made out to EAA Chapter 651 to: |
| EAA Chapter Secretary, Alan Georgia, 620 Memory Ave. Green Bay, WI. 54301 |
| Date:_____/_______/_______ |
| Membership: New ( ) Renewal ( ) |
| Name: (Last) _________________________ (First)________________(MI)______ Birthdate: ____/____/____ |
| Address: (Street) ________________________________________________________ (Apt.)_______________ |
| (City)_______________________________________________ (State)_______________ (Zip)_____________ |
| Phone: (Home) _________________________ (Work)____________________________ (Fax)______________ |
| Spouse:(Name) ___________________________________________________ (Birthdate)_____/_______/____ |
| Children: (Names)____________________________________________________________________________ |
| Employer:_______________________________________________ Occupation:_________________________ |
| EAA Member: ( Yes ) ( No) (Check One) EAA Number: Expiration: / / |
| Pilot Certificate: None ( ) Student ( ) Private ( ) Recreational ( ) Commercial ( ) |
| Ratings: Instrument ( ) Multi ( ) Float ( ) ATP ( ) Other ( ) |
| Aircraft: Owned ( ) Club ( ) Manufacture: ____________________________________________________ |
| Based at: ___________________________________________________________________________________ |
| Current Projects: ____________________________________________________________________________ |
| Past Projects: _______________________________________________________________________________ |
| Other Interests:____________________________________________________________________________ |
| Primary Interest in joining Chapter 651: Learn to fly ( ) Learn to build ( ) Improve flying skills ( ) |
| I just like airplanes ( ) Primarily Social ( ) Good cause will not be active ( ) Other ( ) |
| Comments on Meeting Topics: More Educational ( ) More Social ( ) |
| This is your club. Involvement on your part enhances the overall success of the club! Any activities you might wish to be involved in: |
| Fly-Outs ( ) Young Eagles ( ) Meeting Set-up / Clean-up ( ) Refreshments ( ) |
| Flight Advisor ( ) Newsletter ( ) Meeting Programs ( ) Pancake Breakfast ( ) |
| Party Planning ( ) Other ( ) |
| Name Badge Order: Enclose $ 5.00 for pin back or $6.25 Magnetic back . Amount enclosed: |
| Name as you want it on the badge: Megnetic ( ) Pin ( )Cllip ( ) |
| This information is for the Chapter Directory and to help the board provide a better organization. It will not be released for any commercial reason or mailing lists without your written permission. |
| Instructor ( ) Other ( ) |
| Model: _____________________________________________________N-Number_______________________ |
| Close out Advertising before printing |
| E Mail Address.______________________________________________________________________________ |