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APPLICATION FOR MEMBERSHIP APPLICATION FOR MEMBERSHIP REPA E. Neal Holland, Editor 3491 Pall Mall Drive, Suite 201-B Jacksonville, FL 32257 TITLE (Capt. Mr. or Mrs.). Date NAME (last, first middle) ADDRESS CITY STATE Zip TELEPHONE NUMBER, AREA CODE ( ) NAME CALLED BY SPOUSE'S NAME YOUR DATE OF BIRTH PLACE OF BIRTH DATES EMPLOYED BY EASTERN AIR LINES (from) (to) WAS SPOUSE AN EASTERN EMPLOYEE? ARE YOU A RETIRED PILOT DATE OF RETIREMENT ARE YOU APPLYING FOR AFFILIATE MEMBERSHIP IN REPA WHEN AND WHERE DID YOU LEARN TO FLY? WHAT WAS YOUR CIVILIAN AND/OR MILITARY FLYING EXPERIENCE EASTERN EXPERIENCE PLEASE INCLUDE CHECK FOR $25.00 SIGNATURE Subsequent annual dues are $25.00, payable on your birthday. Affiliate dues are payable on January 1st of each year. Please send dues to the Secretary at the above address. Widows are exempt from dues.
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