Date .tej--- \L.A. \V.' 	Aircraft Make and Model 	Aircraft Identification Mark 	Points of Departure & Arrival 	Mites Flown 	Flight No. 	Remarks, Procedures, Maneuvers, Endorsements 	Number of Landings 	Aircraft Category...
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I certify that Pilot's Signature 	the statements made by me on this form are true. \ (1.,......., id -/I'411„1 /N ., al.,i ,..,,,..., PO, 	Page Total 	7 	''...
Amount Forward 	6 st:3 . :).... I 	.- t.::..._. . 	3 	3 	‘ .3
Total to Date 	" . i 	((,:r(jci ',) ' i 	. 	3 	I \