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Street City State Zipcode

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Home Phone Work Phone Email Address

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Place of Employment

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National EAA No. Approx Date Joined EAA

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FAA Ratings Held (Student, Commercial, Instrument, A&P, A&I, etc) Total Flight Time

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Type Aircraft Flown (Include military)

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Military Service Ratings Held

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Aircraft Presently Owned

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Aircraft Previously Owned

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Current Homebuilt % Complete

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Future Projects or Interests

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Previous Project (s)

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Special Skills, Knowledge, Experience, or Equipment

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Annual Dues are $15.00/person or $25.00/family and are due in January. Make Checks Payable to: EAA Chapter 614