BAOA Membership Application Form – BATESVILLE ASSOCIATION OF AVIATORS

INITIAL ACKNOWLEDGEMENT: “I am at least 18 years old and a US Citizen and understand that by completing this application I am authorizing Batesville Association of Aviators (BAOA) to accept the information I am presenting herein as complete, accurate and truthful to the best of my knowledge.”

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First Name

Please enter your legal first name as it is or will be registered with the FAA.

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Last Name

Please enter your legal last name as it is or will be registered with the FAA.

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Email Address

Please enter a valid email address.

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Confirm Email

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Mailing Address

Please enter your complete mailing address.

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

Phone Number

Please enter the phone number including the area code.

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Alternate Phone Number

Please enter the phone number including the area code.

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Emergency Contact Name and Relationship to Applicant

Please enter the name of an emergency contact person and their relation to you.

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Emergency Contact Phone

Please enter the phone number of your emergency contact.

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Membership Type

Please select your preferred membership type.

Individual

Family

Social/Supporter

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Airman’s Certificate Number, if applicable:

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Please Select All Certificates That Apply:

Private

Commercial

CFI

CFII

ATP

Student/Other

Please Select All Ratings, if applicable:

SEL

MEL

Instrument

SES

MES

Other

Please Select All Endorsements That Apply:

Complex

Tailwheel

High Performance

Other

Total PIC Hours (All Aircraft Types):

If you’re a CFI/CFII how may are Dual-Instruction Hours, if applicable:

Total Hours in a fixed gear SINGLE ENGINE LAND Model Aircraft, if applicable:

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Total Hours in a Cessna 150, if applicable:

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Date of Last Flight Review, if applicable:

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Date of Last Medical Exam, if applicable:

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Class of Medical, if applicable:

Class III

BasicMed

Class II

Class 1

List any Restrictions (e.g. Corrective Lenses, No Night Flights, etc.), if applicable:

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Have you ever had a violation or action against your pilot certificate?

Yes

No

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Have you ever been involved in an accident or incident involving aircraft, reported or not?

Yes

No

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Has your Driver’s License ever been suspended or revoked?

Yes

No

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Have you ever been convicted of any crime or are you under investigation for a crime?

Yes

No

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Have you ever been convicted of any drug related activities, including DUI?

Yes

No

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Have you had any road accidents in the past 5-years?

Yes

No

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Have you ever been denied insurance of any kind?

Yes

No

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If you answered, Yes, to any of the above, please explain in detail here or if you prefer to disclose during the interview or you answered, No, to every question you may leave blank.

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Have you ever been a member of a flying club?

Yes

No

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Additional Comments

Please provide any additional information or comments.

Agree to Terms and Conditions

You must agree to the terms and conditions to proceed.

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