5
Date VA) Aircraft Make and Model Aircraft Identification Mark Points of Departure & Arrival Miles Flown Flight No. Remarks, Procedures, Maneuvers, Endorsements Number of Landings Aircraft Category…
From To IA f R 91—ilik Cr (…E.o62 1-k&L-..1.:(,:i
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I certify Pilot’s Signature that the statements made by me on this form are true. . _…„,\I evi…k1k \ CX2k…?..-, Page Total i Vic, 3-1. 0 S.,:.-.)
Amount Forward 6..” 6-•.- ’ 195 1 T .1 “3
Total to Date 0 (:) VI 1—” 5 I IA 21:75 1 2…C-.,¶