EAA chapter 875 Membership Application

Name _______________________________ Date ___________ [ New / Renewal ] Year ______

Address ___________________________ City_______________ State ______ Zip ________

Spouse/Significant Other ______________________________________

Home Phone____________________ Work Phone ___________________ Cell _________________

Note: We will only call your Home phone unless indicated differently. Chose preferred number (circle)

Email Address ___________________________ Young Eagles Number ________________________

National EAA Membership Number _______________________ Expiration Date _________________

Certifications Held

Type: Airplane Ultra-Light Weight-shift PPC Rotorcraft/Helicopter Airship/Balloon

Ratings: Student Sport Recreational Private Commercial Inst. CFI CFII ATP

Mechanic Ratings: Airframe Powerplant IA

Are you currently flying? Yes / No What? _______________________________________________

Previous Aircraft built: __________________________________________________________________

Current Building project (if any) ___________________________________________________________

Do you any special skills or equipment that you would be willing to share with chapter members

______________________________________________________________________________

Would you be willing top volunteer for chapter events:

Pancake breakfast / Fly-In (July) ___________

Young Eagles (Ground crew) ______________ (Pilot ) ________________

Other __________________________________

May we include this information in a Chapter directory?

May we include this information (Excluding Address and Phone information) on our chapter website?

Neither Both Directory Only Website Only

Annual Membership is $ 20.00

Make checks payable to: EAA Chapter 875

Send to: Bob Viltz

9126 Waldora Rd.

Siren, WI 54872

Additional information on our chapter is available at www.eaa875.org