| Southern Nevada EAA Chapter 1300 |
| P. O. Box 570561, Topaz Station |
| Las Vegas, NV 89157-0561 |
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| Date:________________ |
EAA Membership No.________________ |
| Name:______________________________________________________________ |
| Family Member's Name:________________________________________________ |
| Address:____________________________________________________________ |
| City:_________________ |
State:________________ |
Zip:_________________ |
| Phone:___________________________ |
Cell:_____________________________ |
| Email:______________________________________________________________ |
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| Aviation Interest(s): |
| [___] Experimental |
[___] Ultralights |
[___] Formation Flying |
| [___] Restoration |
[___] Pwrd Parachutes |
[___] Air Racing |
| [___] Antiques |
[___] Fly-ins |
[___] Sky Diving |
| [___] Air Shows |
[___] Classics |
[___] Hang Gliding |
| [___] Aerobatics |
[___] Warbirds |
[___] Sailplanes |
| [___] Young Eagles |
[___] Light Sport |
[___] Fly-outs |
| [___] Other:__________________________________________________________ |
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| Membership Type: |
| [___] Individual: $18.00 (After June 30th - $9.00) |
[___] Life: $450.00 |
| [___] Family: $24.00 (After June 30th - $12.00) |
[___] Family Life:$500.00 |
| [___] Name Badge - $9.50 (Name on Badge):_______________________________ |
| [___] Family Member $9.50 (Name on Badge):______________________________ |
| Cash:_______________ |
Check:______________ |
Check No.____________ |
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| Aircraft Owned: ___________________ |
Building:__________________________ |
| Interested in Building:__________________________________________________ |
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| I would be interested in serving as a [___] Chapter Officer or [___] Director: |
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| I would be interested in serving on the following committee(s): |
| [___] Builder's Support: |
[___] Budget & Finance: |
[___] Flying Activities: |
| [___] Membership: |
[___] Young Eagles: |
[___] Programs: |
| [___] Social: |
[___] Welcome: |
[___] Nomination: |
| [___] Safety: |
[___] Scholarship: |
[___] Other: |
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| I / We agree to uphold the bylaws of Southern Nevada EAA Chapter 1300 |
| and to promote Sport Aviation and Flight Safety in the Las Vegas area. |
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| Signed:_____________________________________________________________ |
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| Signed:_____________________________________________________________ |