(Please print clearly)
Name:
Name as you want on your name badge:
Mailing Address:
e-Mail:
Home phone: Work phone:
Occupation: Retired?:
Pilot (circle): YES NO Aircraft (circle): RENT OWN
Type of flying: % Pleasure + % Business
Qualifications (check box): ¸Private ¸Instrument ¸Commercial ¸ATP
Aircraft Ratings: ¸Single Land ¸Single Sea ¸Multi Land ¸Multi Sea ¸Rotorcraft/Helicopter
Type Ratings:
Special Aviation Interests:
Affirmation: This application is made with the full understanding that the applicant accepts total liability and responsibility for his or her actions during VASI functions, and agrees to hold VASI harmless from any liability arising there from.
Signature: Date:
Send your application along with your check for $20.00 payable to VASI today!
VASI, c/o Paul Hollowell, 417 Mahon Drive, Venice, Fl 34285
