Membership Application

                          PERSONAL INFORMATION
Name:
Address:
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Zip:
                 FLYING AND MEDICAL
 INFORMATION

 
Ratings:
FAA Medical Class:
BFR Due Date:

Hours Last 90 days:
Birth Year:
Phone:
Fax:
Email Address:
Pilot Cert. No.:

 

 
Total Hours:
Medical Date:

Aircraft Flown:
Date of Last Flight:

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LIMA NY Corp. 2111A Smithtown Ave. Ronkonkoma, NY 11779    Tel: 631 580-4445    Fax: 631 580-4446
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