Member #_________

MEMBERSHIP APPLICATION
Please print out this form and mail to the address below with your check.

Silicon Valley EAA Ultralights

Chapter 110

19998 Graystone Lane, San Jose CA,95120
Telephone: 408-997-1657

NAME ____________________________SPOUSE ____________________

ADDRESS_____________________________________________________

CITY _________________________STATE ______ ZIP CODE _________

HOME PHONE (______)___________________

E- MAIL ________________________________

WORK PHONE (_____)___________________

OCCUPATION __________________________

National Membership EAA#_________________

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Indicate below the Membership Category elected.

MEMBERSHIP CATEGORIES (Check one)

Student $free

_____

Chapter $25 ______

Family $35______

Associate$10______

Membership renewal will be on a calendar year basis

TOTAL AMOUNT ENCLOSED $___________

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Signature _________________________ Date _______________