Skip to form
Pilot History Form - Hot Air Balloon
LTA Pilot History
Fields marked with an * are required
First name
*
Last name
*
Street address
*
City
*
State/Region
*
Zip Code
*
Phone number
*
Email
*
Pilot Certificate Number
*
Birthday
Month
/
Day
/
Year
BFA Member Number
Occupation
Drivers License Number
*
Driver's License State
*
_____________________
Pilot Certificate Held
*
Student
Private
Commercial
Year Obtained
Total Time All Aircraft
*
Total Time LTA
*
Approximate Hours in Balloons 90k cuft or less
Approximate Hours in Balloons 90-140k cuft
Approximate Hours in Balloons 140k cuft+
Hours flown in last 12 months
Medical Certificate
Please Select
Class 1
Class 2
Class 3
None
Date Medical Certificate Issued
Month
/
Day
/
Year
_____________________
As a pilot, have you ever had or been involved in any aircraft incidents or accidents?
*
Yes
No
As a pilot, have you ever been found guilty of any Federal Air Regulations violations?
*
Yes
No
Has your automobile driver's license ever been suspended or revoked?
*
Yes
No
Have you ever been arrested for operating an automobile under the influence of alcohol or drugs (DUI)?
*
Yes
No
Have you had any automobile accidents within the last five years?
Yes
No
Please explain any “Yes” answers below.
_____________________
I affirm that the answers given are true and complete to the best of my knowledge and that no material information has been withheld.
*
Yes
No
Type Full Name
*
Today's Date
*
Month
/
Day
/
Year
This pilot record is filed in connection with the insurance application of
*
Submit