Date itfi :XI 	Aircraft Make and Model 	Aircraft Identification Mark 	Pointe of Departure & Arrival 	Miles Flown 	Flight No. 	Remarks, Procedures, Maneuvers, Endorsements 	Number of Landings 	Aircraft Category...
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I certify Pilot's Signature 	that the statements made a s ":.:- 	by me on this form are true.  k if"' 1*-- 4,1-- 	Page Total 	?72- 	.:.;
Amount Forward 	_V1 ..,Vil. 	94 Ti -S32-,; 	'3 	'3 	1 2.. S 1
Total to Date 	'3 	3