LTA Colorado Safety Seminar, Inc.
2012 Pre-Registration Form
Location: The West Metro Fire Training Center
Date: March 3, 2012 – Sign-in starting at 7AM
Please use one form per person.
PLEASE PRINT LEGIBLY!
Name: _________________________________________________________________
Address: _______________________________________________________________
City, State and Zip: ________________________________________________________________________
Phone: H _____________________________ W ______________________________
Email address: _________________________________________________________
Current Certification type: Commercial Private Crew Student
Certificate No.: ______________ BFA Membership #: ______________________
"N" Number : _______________ Make and size of balloon: ___________________
Club Affiliation:
Colorado Balloon Club
BSOPP
Cheyenne Balloon Club
Other______________________________________
How many years have you been a pilot? _____________
How many years as Crew? _____________
How many hours PIC do you have? _____________
How many years have you attended an LTA seminar? _____________
Pre-registration special…..
Received before 12/31/11: Pilot $50.00
Received before 12/31/11: Crew $35.00
Received before 2/15/12: Pilot $55.00
Received before 2/15/12: Crew $40.00
Received after 2/15/12: Pilot $60.00
Received after 2/15/12: Crew $45.00
Amount Enclosed $_____________.00
Mail Check to:
LTA Colorado Safety Seminar
c/o Linda Nash
9914 E. Bayou Ridge Trail
Parker, Co 80134
303-841-0874