Application Membership Application Agreement I am applying for membership in the Octopus Flying Club, Inc., a Maryland not-for-profit corporation with no capital stock. I have read and understand the by-laws and operating procedures of the Club and agree to be bound by them and by any of their subsequent amendments. I am fully qualified for membership in accordance with current by-laws. I understand that as a member I will pay fixed monthly dues beginning with the month during which my membership begins. The amount of the first month’s dues will be prorated in proportion to the number of days remaining in the month. I understand that, in addition to the membership deposit and monthly dues, I will be billed for each hour flown by me in the club aircraft. I am aware of the current flying time costs and fixed monthly fees and that these charges are subject to change by action of the membership in accordance with the by-laws on the basis of good financial practice in a not-for-profit organization. I agree that in the event that the directors of the club approve this application, I will pay the club a membership deposit of $1,200.00. I understand that upon payment of the membership deposit, the member shall have access to all club aircraft that he/she is qualified to operate. I agree that giving false information on this form will be cause for rejection of my application, or, if false information is discovered after I am a member, it will be cause for my immediate expulsion from membership without reimbursement of any money paid to the club. I agree to the terms listed above.* *This checkbox must be checked before continuing. General Information Last Name: **Please enter your last name. First Name: **Please enter your first name. Home Address: **Please enter your home address. Appartment: City: **Please enter your home city. State: **Please enter home state. Zip-Code: **Please enter your home zip-code. Home Phone: **Please enter at least one phone number. Cell Phone: **Please enter at least one phone number. Email Address: **Please enter your email address. Date of Birth: **Please enter your date of birth. Citizenship: **Please enter the name of your country of citizenship. Employment Information Employer Name: Employer Address: Employer City: Employer State: Employer Zipcode: Work Phone: Email Address: Occupation: Pilot Information Certificates Held: Student Pilot Private Pilot Commercial Pilot ATP Other Certificate **Please select at least one certificate. Ratings Held: Single Engine - Land Multi Engine - Land Instrument - Airplane Other Rating **Please select at least one rating. Medical Certificate: Please Select First Class Second Class Third Class Basic Med **Please select your current medical certificate. Date of Last Medical: **Please enter the date of your last FAA medical. Date of Last Flight Review: **Please enter the date of your last flight review or most recent successful check-ride. Certificate Limitations: Pilot Certificate Number: **Please enter your pilot certificate number. Has your driver's license ever been revoked or suspended: Please SelectNoYes **Please answer if your driver's license has been revoked or suspended. Has your pilot certificate ever been revoked or suspended: Please SelectNoYes **Please answer if your pilot certificate has been revoked or suspended. Have you had any aviation violations, mishaps or losses: Please SelectNoYes **Please answer if you had any aviation violations, mishaps or losses. Have you been convicted of operating a motor vehicle under the influence of alcohol or drugs: Please SelectNoYes **Please answer if you have been convicted of operating a vehicle under the influence. Have you been convicted of a felony: Please SelectNoYes **Please answer if you have been convicted of a felony. If you answered yes to any of the previous questions, please provide details: **Please provide details for any 'Yes' answers. Flight Time: Total Flight Hours: **Please enter your total flight hours. Night Hours: **Please enter your total night flight hours. Flight Time in Last Six Months: Recent Flight Hours: **Please enter your total flight hours in the last six months. Recent Night Hours: **Please enter your total night flight hours in the last six months. Acknowledge and Submit By submitting this form I declare that the information provided in this document is true, accurate and complete to the best of my knowledge.* *This checkbox must be checked before submitting.
