Join Club Takeoff

Member Information

First Name

Middle Name

Last Name

Phone

Email *

Country

Birthdate

Account Information

Username

Password *

Confirm Password *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Pilot Certificate

Pilot Certificate Number

Date of Last Flight Review (or Rating)

Ratings

ASELASESAMELAMESIRCFICFIIGliderRotorcraftHigh PerformanceTailwheelComplexPlease check all ratings that apply.

Current Medical Certificate Type

Medical Expiration Date

Memberships

Are you an AOPA Member?YesNo

AOPA Number

Are you an FAA WINGS Member?YesNo

Disclosures

Have you ever been involved in an aircraft accident?NoYes

Have you ever been convicted of drug or alcohol offenses?NoYes

Have you ever been denied aircraft insurance?NoYes

Have you had a moving violation within the past three years?NoYes

Have you ever been penalized or disciplined for violating any FAA regulations?NoYes

Have you been suspended or denied membership from any flying club?NoYes

Are you flying with any waivers (medical or otherwise)?NoYes

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Consent

I agree with the terms and conditions of all Club Takeoff membership including Club Rules, Bylaws, Code of Conduct, and Membership Agreement. I consent for my payment information t obe be charged for any and all flight fees I should incur as per the membership agreement.

Your SignaturePlease type your name as your signature and verification of consent.