Date igj ..'?.,(- 	Aircraft Make and Model 	Aircraft Identification Mark , 	Points of Departure & Arrival 	Miles Flown 	Flight No. 	Remarks, Procedures, Maneuvers, Endorsenisnts 	Number of Landings 21.9.p.r,71, 	Aircraft Category...
From 	To 	4L-c-,aduzkL
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I certify Pilot's Signature 	that the statements made by me on this form are true. , I 0,,x(.-1\ raiz  	Page Total 	7A- 	2_3
Amount Forward 	(a ( 16 ---5C11-2- 	1 404 	% 	3 	3
Total to Date 	5%c-k-1 	i-a.c)3 	b 	") 	3 	1.1