Date le-- 	Aircraft Make and Model . 	Aircraft Identification Mark 	Points of Departure & Arrival 	Mlles Flown 	Flight NO. 	Remarks, Procedures, Maneuvers, Endorsements 	Number of Landings 	Aircraft Category...
, ucs3 	From 	To 	AD': poic- 	G.Lmiz
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22:i,A, 	\ / 1 	9
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I certify Pilot's Signature 	that the statements made by . ( D .„„..., '' — J j2L-1 	me on this form are true. ,. , 	Page Total 	i 	!:.;(t5 	z	—
Amount Forward 	6.11b .i 	C 9 1-1 i •-•,-- 	`‘.-- .'N 	..2, J
Total to Date 	1..,) '!AA 	. LO-C),S- 	1 	?) 	' 	1 1....- ,