EAA Chapter 421 Membership Form
It is important to keep membership information current. In order to do this, the EAA Chapter authorized the development of an updated electronic membership form so that it would be easy to collect membership information. Please take the time to complete this form as soon as possible.

If you are not a current EAA National Member, it is required that you go to the following URL and register as an EAA member. You will then receive an EAA National Member number. You will need this number later in the application process.

https://www.eaa.org/shop/Membership/Join.aspx?msclkid=6fca852ad744118fe0eee76333debfa2
Sign in to Google to save your progress. Learn more
Email *
EAA Chapter 421 -- Current Logo
Last Name *
First Name *
Middle Initial *
Gender *
Age Today *
DOB *
MM
/
DD
/
YYYY
Street Address *
PO Box or Apt. Number if Needed
City *
State *
Zip Code *
Primary Phone # *
Type of phone *
Are you able to receive text messages? *
National EAA Number (on your card) *
How did you hear about the Urbana-Grimes EAA Chapter 421 Aero Club? *
What motivates you to be a part of the Urbana-Grimes EAA Chapter 421 Aero Club? *
Please list your skills, attributes, and or interests that you believe will benefit the Urbana-Grimes Chapter 421 Aero Club. *
Briefly describe your primary vocation. *
Are you currently serving in the US Military? *
If yes, what branch of the US Military is your association?
Clear selection
Are you a military veteran? *
Do you have a private pilot certificate? *
Do you have a commercial pilot certificate? *
Are you a certified flight instructor (CFI)? *
Do you own an aircraft? *
If yes, what type of aircraft and is it currently certified to be in active service?
Primary Emergency Contact Person's Name *
Emergency Contact Person's Relationship *
Emergency Contact Person's Street Address *
Emergency Contact Person's City *
Emergency Contact Person's Zip Code *
Emergency Contact Person's State *
Emergency Contact Person's Phone # *
Emergency Contact Person's Phone Type *
Emergency Contact Person's E-Mail Address *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of EAA Chapter 421. Report Abuse
Google Forms