Name _____________________________________________ Date __________________

Address___________________________________________________________________

__________________________________________________________________________

Phone ________________ Fax ____________________ E-mail: ____________________

Preferred dates for training: ________________________________________________

Flight certificates held (if any): _____________________________________________

______________________________________________________________________

Previous documented balloon flight instruction (if any): Total Hours: __________

Instructor(s): ___________________________________________________________

________________________________________________________________________

Age _____ Sex _____ Health ___________

Minimum deposit to reserve dates: $1,000.00. Balance due at commencement of training.

Amount enclosed: $___________