Welcome to 27th Annual Arkansas Hot Air Balloon State Championship Pilot Registration Form                                                  
September 9, 10 & 11, 2022
Being Held at the Anstaff Soccer Complex
202 Old Stonewall Road, Harrison, AR 72601
Registration Deadline is Noon, September 1, 2022
Contact: Renée Swanson
Explore Harrison
200 W. Stephenson
Harrison, AR 72601
870-741-1789
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Pilot's Name: *
Address, City, State and Zip: *
Phone Number: *
Email Address: *
Pilot Certificate Number: *
Balloon Number: *
Balloon Name: *
Balloon Description: *
Date of Manufacture: *
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/
DD
/
YYYY
Private or Commercial: *
Total PIC Hours: *
Number of PIC Hours in the Last 12 Months: *
Last Biennial: *
MM
/
DD
/
YYYY
Occupancy of Basket: Pilot + *
Weight Limit: *
Insurance Carrier: *
Insurance Policy Number: *
Insurance Period: *
Required Insurance Minimums of $100,000 minimum per passenger, $300,000 minimum, combined single limit B.I./P.D. *
Required
How many crew members do we need to secure for you? *
Will You Be Tethering? *
Pilot Shirt Size: *
Complimentary Pilot Hotel Room: *
$50 Registration FeeCredit Card #, Expiration Date & CVV: **You will NOT receive notification that the credit/debit card was accepted ... For verification, please call 870-741-1789 ... Do NOT re-enter your information**    OR      You may mail us a check. *
Your registration fee will be returned along with an additional $50 on Sunday, September 11, 2022 *
I certify that the hot air balloon listed above has a standard airworthiness certificate and that it has been inspected in accordance with FAA requirements within the last year. I also certify that I hold a pilot's license for this event, have had a current biennial check ride and carry the required insurance as stated above. *
Required
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