Date 19_ .065 	Aircraft Make and Model 	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 	that the statements made by me on this form are true. ....-.„.  C.E: Signature e J 1.-. ' 1, -tok ri:.(TC210 	Page Total 	373 	cr;C 	:)—
Amount Forward 	4,(:.•,..10 -5.,-- 	L'1 15 0 	2 	1 	'1.) 	k 1 i
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