Date I.e."! .,--	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 Pilots Signature 	that the statements made by me on this form are true. .,.. t. . ' i n •----) co-tot 1.e.j.:1)  1-1.-- 	Page Total 	t bi‘, 	SO 	4-
Amount Forward 	VIVI 	Ci 1 11 	`'
Total to Date 	IL,C?.13 ( 	91-1 • •II ( 	--, 	'2 	-IN 	1 )