Southern Nevada EAA Chapter 1300
			P. O. Box 570561
			Las Vegas, NV 89157-0561
Date:________________				EAA Membership No._________________
Name:_________________________________________________________
Family Member's Name:___________________________________________
Address:_______________________________________________________
City:_______________________				State:________		Zip:_________________
Phone:_____________________						Cell:________________
Email:_____________________________________________
Aviation Interest:
[___] Experimental			[___] Ultralights			[___] Formation Flying
[___] Restoration			[___] Pwrd Parachutes			[___] Air Racing
[___] Antiques			[___] Fly-ins			[___] Sky Diving
[___] Air Shows			[___] Classics			[___] Hang Gliding
[___] Aerobatics			[___] Warbirds			[___] Sailplanes
[___] Young Eagles			[___] Light Sport			[___] Fly-outs
[___] Other:__________________________________________
Membership Type:
[___] Individual: $18.00 (After June 30th - $9.00)						[___] Life: $450.00
[___] Family: $24.00 (After June 30th - $12.00)						[___] Family Life:$500.00
[___] Name Badge - $9.50 (Name on Badge):__________________________
[___] Family Member $9.50 (Name on Badge):_________________________
Amount Paid:		Cash:________		Check:_______		Check No. __________
Aircraft Owned: ___________________________					Building:____________________
Interested in Building:_____________________________________________
I would be interested in serving as a [___] Chapter Officer or [___]Director:
I would be interested in serving on the following committee(s):
[___] Builder's Support:			[___] Budget & Finance:			[___] Flying Activities:
[___] Membership:			[___] Young Eagles			[___] Programs:
[___] Social:			[___] Welcome:			[___] Nomination:
[___] Safety:			[___] Scholarship:			[___] Other:
I/We agree to uphold the bylaws of Southern Nevada EAA Chapter 1300
and to promote Sport Aviation and Flight Safety in the Las Vegas area.
Sign:_______________________________________
Sign:_______________________________________