Westchester Flying Club
New Member Application

Basic Personal Information
Today's Date:
MM/DD/YYYY
First Name:
Last Name:
Birth Date
 MM/DD/YYYY
Street Address:
Address (additional)
City:
State
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Email:
Years at Home Address:
Employer:
Employer Address
Employer City:
State:
Zip Code:
Job Title:
Years at this Employer:
Are you a United States Citizen?:
 Yes No
If not, Nationality?
Years in US?
Flying Background & Plans
Pilot License Number:
Date Issued:
 MM/DD/YYYY
Certificate Type:
 Student Pilot
Recreational Pilot
Private Pilot
Commercial Pilot
Airline Transport Pilot

Date of Last Rating:
 MM/DD/YYYY
Ratings:
(check all that apply)
SEL SES
MEL MES
Instrument - Airplane CFI
CFII  
Limitations:
Medical Certificate Class:
 3rd
2nd
1st
Last Medical Date:
 MM/DD/YYYY
Hours:
 Total: PIC:
Last 12 Months: Dual:
Where did you learn to fly?:
Where have you flown most recently?:
(meaning, which FBO, club, etc.)
How long a relationship with that organization?:
 years. (If less than 1 year, just enter 1)
Have you ever been involved in an aviation incident/accident?:
 Yes No
If yes, provide brief details:
Have you ever been cited by the FAA or similar authority?:
 Yes No
If yes, provide brief details:
Estimated montly flying hours?
(Estimate based on last 6 months.)
How many hours/month do you expect to fly as a member of the WFC?:
What fraction of your flying is business vs. pleasure?:
 % business
In what types of aircraft have you logged time?:
aircraft
estimated time
What have you been flying most recently?:
Member Committee Confidential Personal Information
The following information is CONFIDENTIAL to the membership committee.
Current Monthly Income: $ .00
Current Monthly Expenses: $ .00
Rent or own your home: Rent Own
Social Security Number:
Have you ever declared personal or business bankruptcy?: No Yes
Has you medical condition changed since your last examination? No Yes
If so, have you consulted an AME to certify the validity of your present medical certificate (cf. 14 CFR 61.53) Not Applicable Yes
Have you ever been convicted of driving while under the influence of alcohol or any other controlled substance? No Yes
In the past 5 years, have you ever had your driver's license suspended or revoked? No Yes
Have you ever been convicted of a felony or misdemeanor? No Yes
Have you ever been denied insurance coverage for the operation of an aircraft? No Yes
Have you ever had insurance for the operation of an aircraft cancelled? No Yes
Please provide the names, addresses, home and business phone numbers and email addresses, if available, for two persons who we may contact regarding a reference on your personal background and character. One should be your employer or a prominent member of your community and one should be affiliated with a flying organization with which you have had significant contact (e.g. FBO owner/manager or flight instructor).
Name: Name:
Home Phone: Home Phone:
Work Phone: Work Phone:
Email: Email:
Refernce Type:

Business
Flying
Personal

 Reference Type: Business
Flying
Personal
Member Committee Confidential Personal Information
Membership Level Applying for
General
  Entry Fee: $1,600 Monthly Dues: $170

Aircraft Available: All aircraft, provided any aircraft specific special training or experience requirements are met per club Rules & Regulations.
I understand that by I am expected to enclose my entry fee for my chosen class of membership plus one month's dues along with this application.

Check box to indicate acceptance.
I further agree that upon presenting myself personally to the membership committee, that I'll be required to personally sign a printout of this document.

Check box to indicate acceptance.

I agree to provide copies of my pilot's license, driver's license, medical certificate and relevant parts of your logbook showing currency, BFR's, check rides, etc.

These should be initially be sent along with application materials. Ongoing record keeping will be per current club policies.

Our Confidentiality Statement...

The information provided will only be made available to the WFC Executive Committee and the WFC Membership Committee, and to the membership at large but not any non-member, unless required to be made available by a court of law, the FAA or similar authority, except that information in the "Confidential" paragraph will not be made available to the membership at large without the express permission of the applicant. All information provided will only be used for the purposes of determining whether the Applicant may be a suitable person to be invited to join WFC.

Your Certification Statement...

I certify that I have read and understand the WFC's By-Laws and Operating Rules and agree to abide by them and be bound by them. The information I have provided is true and accurate to the best of my knowledge and I understand and agree that the submission of any false or misleading information will likely result in instant dismissal from the Club. I hereby authorize WFC to carry out any background checks regarding any of the information provided here or any other information it considers relevant to this application or my on-going membership of WFC, with any public or private agency. These checks may include but may not be limited to checks on financial status, legal status, flying status, medical status, character, etc. Furthermore, I agree that should these background checks reveal the submission of any false or misleading information on my part, I will reimburse the WFC for any costs incurred not to exceed $100 and authorize the Club to deduct such costs from my Application Fee. I understand that upon being admitted to the WFC, my membership is provisional for a period of three months. During this time I will be able to enjoy all the privileges available to full members of the Club but my membership may be revoked at the discretion of the Executive Committee should it subsequently decide that, for whatever reason, I am not a suitable person to be a member of WFC. In such an event, I will be entitled to a full refund of my Application Fee (less any expenses as described above).


Check box to indicate acceptance.

Please sign and date this application:

Signed: ____________________________ Date: _______________________

Please send this application and check to:

Judah Holstein
64 Morgan street
Eastchester, NY 10709