Patuxent River Navy Flying Club

Patuxent River Navy Flying Club
Membership Application

Last: ______First: ______

I hereby apply for membership in the Patuxent River Navy Flying Club (also referred to as “PRNFC” or “the Club”).

______I understand that I must provide proof of United States Citizenship or Nationality by providing a valid, unexpired passport or an original government-issued certified birth certificate of the United States, American Samoa, or Swains Island, together with a government issued picture identification of the individual or an original United States naturalization certificate with raised seal, or a Certificate of Naturalization issued by the U.S. Citizenship and Immigration Services (USCIS) or the U.S. Immigration and Naturalization Service (INS) (Form N-550 or Form N-570), together with a government issued picture identification of the individual or an original certification of birth abroad with raised seal, U.S. Department of State Form FS-545, or U.S. Department of State for DS-1350, together with a government issued picture identification of the individual.

______If I leave my account unpaid, after reasonable attempts have been made to contact me, my name and contact information may be submitted to MWR for further action which could include notification of my Commanding Officer (military members), or other debt collection procedures (civilian members).

______I understand that any change in my membership status, requested by me, requires advance written notification and that failure to fly, attend club meetings, or otherwise participate in club activities does NOT automatically downgrade my membership status to inactive or terminate my membership, nor does it relieve me of my financial responsibilities towards the Club. Unless otherwise approved by the Board, any change in membership status will take effect no less than 30 days following receipt of the request. I further understand that a request for resignation will not be approved/take effect until all financial obligations I have accrued while in the Club have been met, and that monthly dues will continue to accrue until my account balance is paid in full. I further understand that the board may, for reasons of best interests of the Club, change my membership status without my consent. I will be notified of any changes to my status imposed by the board by the most expeditious means available.

______I understand my financial obligation for liability in case of aircraft incident/mishap is up to $2,500.00 for damages, including recovery costs to any PRNFC aircraft I operate as a student pilot or pilot-in-command.

______I understand that I am obligated to keep the Club informed of any change in my e-mail and mailing addresses, employer, emergency notification information, and telephone information listed on my application, or any change in my status that affects my eligibility for membership.

Basis for membership:

Military Service Rank Status Civilian

☐US Navy ☐O-1 or above ☐Active Duty ☐Civil Service

☐Other US Service ☐E-6 or above ☐Reserve ☐DOD Contractor

☐Foreign Military ☐E-5 or below ☐Retired ☐Dependent

☐ROTC Midshipman/CADET or

Civil Air Patrol

VOLUNTARY WAGE DEDUCTION CONSENT / AGREEMENT

I consent to collection for any amounts due from me to the U.S. Government or its instrumentalities for unsettled debts plus applicable reasonable service charges that have been incurred by me or my family member(s) with the Patuxent River Navy Flying Club. By signing below I hereby certify that I have read and understand the club regulatory documents, and understand my responsibilities as a club member as set forth in those documents and this agreement.

______

Applicant Signature Date

______

Applicant Printed Name Last 4 SSN

INITIAL PAYMENT

Fill in the appropriate dollar value on each line and write the total on line 4.

1. Membership fee: $40.00 Individual / $60.00 Family, OR Letter of Good Standing from military flying club attached (one-time fee).

2. Processing Fee: $10.00 per Individual (one-time fee)

3. First Year Annual Dues (see Manager for exceptions):

Annual / Monthly / Category
$275.00 / $25.00 / Civilian and E-6 or above
$165.00 / $15.00 / E-5 or below
$330.00 / $30.00 / Family

4. Total amount received. CHECK (made out to PRNFC) or CREDIT CARD only

FAA CERTIFICATES

Circle the appropriate certificate(s) that you now hold and list any logbook endorsements (i.e. high performance, complex) and/or type ratings below:

Student / Recreational / Private /

Commercial

/ CFI / CFII / ATP

Certificate Number(s): ______

Endorsements and type ratings: ______

MEMBER CONTACT INFORMATION

Last: ______First: ______

Home phone: ______Home email: ______

Work phone: ______Work email: ______

Mobile phone: ______

Home Mailing Address: ______

______

______

Employer: ______

Work Mailing Address: ______

______

______

EMERGENCY CONTACT INFORMATION

NAME: ______RELATIONSHIP: ______

ADDRESS: ______

______

______

HOME PHONE: ______MOBILE: ______

PATUXENT RIVER NAVY FLYING CLUB

COVENANT NOT-TO-SUE AND INDEMNITY AGREEMENT per BUPERSINST 1710.22

I, ______am about to participate voluntarily in various activities, including flying activities, of the Patuxent River Navy Flying Club (Patuxent River, MD 20670) as a pilot, student pilot, copilot, instructor, or passenger. In consideration of the Flying Club’s permitting me to participate in these activities, I, for my heirs, administrators, executors and assignees, hereby covenant and agree that I will never institute, prosecute, or in any way aid in the institution or prosecution of, any demand, claim or suite against the U.S. Government and/or its officers, agents, or employees, acting officially or otherwise, for any loss, damage, or injury to my person (including death) or my property which may occur from any cause whatsoever as a result of participation in the Flying Club.

If I or my heirs, administrators, executor, and assignees should demand, claim, sue or aid in any way in such a demand, claim or suits, I agree to indemnify the U.S. Government for all damages, expenses and costs it may incur as a result thereof.

I understand and agree that I am assuming the risk of death, any personal injury or property damage to me that may result while participating in Flying Club activities, including such injuries or damage that may be caused by the negligence of the U.S. Government.

I also understand and agree that I may be held liable for any damage or loss to the U.S. Government which is caused by my gross negligence, willful misconduct, or fraud.

The term U.S. Government as used here includes the Patuxent River Navy Flying Club, including individual members and any officer, agent or employee of the U.S. Government/or the Flying Club, acting officially or otherwise.

Date ______Signature______Witness______

Date ______Signature______Witness______

NOTE: If a minor, so indicate and state age. The minor will sign if capable of signing. If not capable, have parent sign for the minor, i.e., “John Jones by Harry Jones, his father”. In all cases for minors the following form must additionally be completed.

I/We ______, parents of the above-said minor child, do hereby (1) consent to my child

______participating in the Patuxent River Navy Flying Club activities, (2) agree

(Child’s Name & Age)

to and adopt as my/our own the conditions of the above agreement, and (3) agree to reimburse the U.S. Government for any damage incurred by it for which my child would have been liable had my child reached the age of majority.

Date ______Parent’s/Guardian’s Signature ______

Witness Signature ______

Date ______Parent’s/Guardian’s Signature ______

Witness Signature ______

Note: For club member, must be signed annually (at time of annual flight check; for guests/dependents, must be signed prior to each flight).

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Revised 5/22/2015