Last Name: ___________________First Name:_____________

If married, Wife's Name:____________  

If any, Children's Names:_________________________________

Street Address:________________________________________

City:______________________  State:_______ Zip: _____-____

Home Phone: __________  Work Phone:__________________

Email Address:_______________________________________

(For mail-outs to you and members ONLY!

Not shared with anyone else!)

EAA Number: __________________________Expires: _______

(Not a requirement to be a Chapter 541 member, but advisable.

  Must be a National member to be an Officer or Board Member)

If you own an aircraft, which type?: ______________________

N Number:________________

Building an aircraft, which type?:________________________

Give us a little background on you and your family. 

What aircraft, projects, or aviation interests do you have?

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