Date 19 	Aircraft Make and Model S 	Aircraft Identification Mark 	Points of Departure & Arrival 	Miles Flown 	Flight No, 	Remarks, Procedures, Maneuvers, Endorsements 	Number of Landings 	Aircraft Category...
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I certify Pilot's Sio-Rture__________________ 	that the statements made 	by me on this form are true. 	Page Total 	t (‘ 6 	--1.5% 	'-1
Amount Forward 	k(,L V-13 	W)<KL 	3 	3 	I \ /- (
Total to Date 	(2 k Lk c1 	\ Vi- (