Date-   ___________________________

Name- ______________________________________________________
Address- ____________________________________________________
Postal Code- _____________________________
Tel. Home- ___________________  Cell. _____________________
E-mail - ____________________________________________
Spouse/Partner - _________________________________________

Aircraft - __________________________________________________
Registration- _____________________________________
COPA # - __________________________Exp Date __________

Other aviation affiliations - __________________Exp Date (s) _______________________
License and ratings - ____________________________________

I agree to adhere to the Havelock Flying Club Inc. by-laws and operational directives and I understand that it is a member operated and maintained club and as such my participation in club activities and work efforts will be expected.
Sig. _______________________________________
Approval date - __________________________

Authorized by- ___________________________________   Sig. ________________________________________

Copa National Org.

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