Last Name: ______________ First Name: ________________

Mi: ___ Age: ____ Occupation: ___________________

Street & Apt.: __________________________________________

City: _________ State: _______ Zip Code: ___________

E-Mail Address: ________________________

Home Phone: _____________ Work Phone: _____________

AMA Number: _________ IMAA Number: ______________

DO YOU RENT OR OWN YOUR RESIDENCE __________

DO YOU HAVE HOME OWNERS OR RENTERS INS. __ YES __ NO

RADIO CHANNELS YOU HAVE _________________

NUMBER OF YRS FLYING R/C _____

YEARLY DUES ARE $125.00 PER YEAR FOR OPEN MEMBERS. JAN.1 THRU DEC. 31.

MAKE CHECKS PAYABLE TO RALPH TUTOR FOR THE FULL AMOUNT MAILING ADDRESS:

8221 TUTOR-STEPHENS RD.
HOLLY SPRINGS, N.C. 27540

SIGNATURE: ____________________

DATE: _____________

NOTE: YOU MUST HAVE CURRENT AMA TO FLY AT THE SWAMPS FLYING FIELD