FINGER LAKES AREA PILOTS, INC.

P.O. BOX 606

SENECA FALLS, NY 13148

 

MEMBERSHIP APPLICATION

 

First Name:_____________________ MI:____ Last Name:_____________________

 

Street Address:____________________________ City:_________________________

 

State:___________ Zip:__________________ SS#_______/_______/___________

 

Home Phone:(___)_______-__________ Work Phone:(___)______-________________

 

E-Mail:_________________________________ Date of Birth:______/______/______

 

Pilot Certificate Held (circle): None Student Recreational Private Commercial ATP

 

Ratings (circle all that apply): INST SEL MEL CFI CFII OTHER_______________

 

Total Flight Hours: _______________ Hours in last 12 Months:__________________

 

PA-28 Hours: _______________ PA-28 Hours in last 12 Months:________________

 

Date of FAA Medical: ____/____/____ Date of Biannual:____/____/____

 

Any FAR Violations: Yes No (circle)

 

If you answer yes to either of the following two questions, please provide details on a separate sheet.

 

Has your driver's license ever been revoked or suspended?: Yes No (circle)

 

Have you ever been convicted of a drug or alcohol related offense? Yes No (circle)

 

 

Please mail completed application to

Finger Lakes Area Pilots, Inc.

P.O. Box 606

Seneca Falls, NY 13148

________________________________________________________________________