Your Name:
Address:
City State Zip:
Telephone Home:
Telephone Work:
Telephone Cell:
Email address:

Number of passengers:      Total combined passenger weight:   lbs.

If you are purchasing a Boarding Pass/Gift Certificate(s) without selecting a reservation date, please skip the next 3 lines.

Reservation date (1st choice):	Sunrise Pre-sunset
Reservation date (2nd choice):	Sunrise Pre-sunset

If redeeming a Gift Certificate(s), provide number(s):

If this is a new purchase, enter your total cost:  Passengers/cost1 / $2502 / $5002 Private / $6503 / $7503 Private / $8504 / $1,0005 / $1,2506 / $1,5007 / $1,7508 / $2,000
Deposit/Payment amount:    (Gift Certificates must be paid in full. Flight deposits require a minimum of $50 per passenger.)
Payment method: VISA  MasterCard  Discover Card  Check-(mail copy of this completed form with your check)
WARNING: As of this date, this form is NOT encrypted for securely transmitting credit card information. Please call Eastern CT Balloon Services, Inc. at 860-376-5807 to provide credit card information. You can fill in your credit card information below if you plan on printing and faxing (fax 860-376-5101) or mailing this form to us.
Credit Card Number:    Exp. Date: Month123456789101112 / Year200720082009201020112012201320142015  3-digit CVV code:  (on back of card)
Signature:  

Any questions or comments? (i.e. How many Boarding Pass/Gift Certificates are you purchasing? How many passengers per Boarding Pass/Gift Certificate? The name(s) you want typed on each Boarding Pass/Gift Certificate? Are you rescheduling a canceled flight? When was your last reservation? Do you have a deposit on file with us? etc.)