August 21 & 22, 2009

Official Pilot Entry Form
Madison RibberFest Balloon Race

Minimum License Requirements: Private Hot Air Balloon Certificate

Pilot Information

(Please type or print)

Name:_____________________________________________________

Address:___________________________________________________

City:______________________________________________________
State:______________________________________________________
Zip Code:_______________

Home Phone: _______________________________________________
Cell Phone: _________________________________________________

Fax: ___________________________________________

Certificate Number: ___________________________________________

Date of Last Biannual Flight Review: _____________________________

Hours Logged in Hot Air Balloon: _______________________________

Balloon Information

Company/organization/Name of Balloon:_____________________________

Balloon Make: _____________________________________

Model: ___________________________________________

Year: ___________________________________________

Registration Number:_______________________________________

Hours on Balloon: _________________________________________

Passenger Capacity: ________________________________________

Date of Last Annual Inspection: _______________________________

Insurance Company Name: ___________________________________

Dates of Policy: Limits: ______________________________________

*Please include a certificate of insurance naming Madison RibberFest as holder.

Address___________________________________________
_________________________________________________

City:___________________________________________
State: __________________________________________
Zip Code: _______________________________________

Policy Number:____________________________________
Expiration: _______________________________________

Indicate Shirt Size: L XL XXL

(Circle One)

I agree to obey the Rules of 2009 RibberFest Balloon Race and adhere to good sportsmanlike conduct. I also agree to bring with me a current pilot's license, valid certificate of insurance, and any other official documentation concerning the balloon, which the organizers may request.

I certify that the above information is accurate:

Signature of Pilot:___________________________________________

Date: ___________

Return to:

Mindy Cloud

7837 W Polk Road

Lexington, IN 47138

Attn: RibberFest Balloon Race