FIRST NAME: MIDDLE:

LAST:     "NICKNAME" :

SPOUSE'S NAME:

ADDRESS:  

CITY:     STATE:     ZIP CODE:

HOME PHONE: WORK PHONE: EXT:

CELL PHONE:   FAX:

E-MAIL: 2nd E-MAIL:

DUES INFO.      AMOUNT PAID: DATE PAID: YEAR PAID FOR:

EAA MEMBER #: EXP. DATE:

AIRCRAFT OWNED:     N-NUMBER:

2nd AIRCRAFT OWNED:      N-NUMBER:

AIRCRAFT BUILDING:      N-NUMBER:

RATINGS:    ATP:           COMMERCIAL:           INSTRUMENT: PRIVATE: CFI: CF II: MULTI ENG:
SINGLE ENG: HELICOPTER:        SPORT PILOT:             GLIDER RATING:

ACTIVITIES:      BUILD: HELP BUILD: ACTIVITIES:  YOUNG EAGLES: INSTRUCT:  CHAPTER OFFICE:
RESTORATION: ULTRA LIGHT: MEDIA PR: VOLUNTEER SUN-FUN: OTHER: