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1978 Cessna 172
1991 Grumman Tiger
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Application Form
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Name*
Address*
Your email*
Message*
ODL*
Occupation*
Employer*
Business Address
Work Phone
FAA Medical Certificate held*
Total Hours Logged*
Last 12 Months*
Ratings*
Date of last Flight Review*
FAA Violations or Accidents/Incidents last 5 Years?*
Yes
No
During the past 5 years, have you been convicted or entered diversion for any motor vehicle violations including driving under the influence of alcohol or a drug or had your driver’s license suspended or revoked?*
Yes
No
During the past 5 years, have you been involved as a driver in any motor vehicle accident?*
Yes
No or zero
Reference 1*
Reference 2*
Reference 3*
Remarks/Explanations
Consent*
By Checking the box. I authorize Salem Pilots Association to check references, driving records and other sources of information available tothem. I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge. If accepted as a member, I agree to abide by all rules of Salem Pilots Association and to be bound by the Association’s By-laws and Flight Rules.
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