NAME:________________________________________________________NATIONAL EAA #____________

ADDRESS:__________________________________________________

CITY:_____________________________________STATE:______________________ ZIP:______________

HOME PHONE:___________________________ WORK PHONE:_____________________

E-MAIL ADDRESS:__________________________________________

SPOUSE OR MATE'S NAME:_________________________________

PILOT RATINGS: _______________________ MAINT. RATINGS:____________

_______________________ ______________________________

_______________________ ______________________________

AIRCRAFT OWNED AND FLYING:_____________________________________________

AIRCRAFT UNDER CONSTRUCTION:__________________________________________

ENGINE USED IN PROJECT:___________________________________________________

LIST AIRCRAFT BUILDING SKILLS YOU HAVE:________________________________

______________________________________________________________________________

ARE YOU WILLING TO HELP OTHERS:_________

ARE YOU WILLING TO BE A CHAPTER OFFICER OR DIRECTOR:_________

ARE YOU INTERESTED IN PARTICIPATING IN YOUNG EAGLES RALLIES:______

IF YES, AS GROUND CREW:____________ OR AS PILOT:__________

YOUNG EAGLES ID #:________________

DUES PAID TO:____________________________ TREASURER'S INITIALS:_________