Part 40, page 384

Transcript

The scan is the source; the transcript is machine-generated from it.

REGISTRATION FEE $4.00 ORS 493.050

OREGON PILOT REGISTRATION RENEWAL REMINDER REGISTRATION PERIOD FROM 01/01/78 TO 12/31/79

PLEASE REVIEW THE BELOW INFORMATION. CROSS OUT ENTRIES IN ERROR AND WRITE IN THE CORRECT INFORMATION. FAA PILOT CERTIFICATE NUMBER MUST BE ENTERED BY ALL BUT STUDENT PILOTS.

FAA PILOT CERTIFICATE #: 2104631 FAA STUDENT PILOT #: NOT APPLICABLE

DATE OF BIRTH: 10-16-43 Mo. Day Year RACKSTRAW, ROBERT W HOME PHONE: 7721245 PO BOX 352 BUSINESS PHONE: 7721756 VALLEY SPRINGS CA 95252 OREGON COUNTY(NON-OR STATE): CALIFORNIA

FOR AIRCRAFT OWNERS ONLY INSTRUMENT RATING: YES AIRCRAFT OWNER: NO AIRCRAFT USED FOR BUSINESS: N.A. FLIGHT INSTRUCTOR: YES FAA AIRCRAFT #: N.A. AIRCRAFT USED FOR PLEASURE: N.A.

***HIGHEST PILOT CERTIFICATE*** ***********TYPE OF AIRCRAFT RATING************* STUDENT: NOT APPLICABLE SINGLE-ENGINE-LAND: YES GLIDER: NO PRIVATE: NOT APPLICABLE SINGLE-ENGINE-SEA: NO HELICOPTER: YES COMMERCIAL: YES MULTI-ENGINE-LAND: YES BALLOON: NO AIR TRANSPORT: NO MULTI-ENGINE-SEA: NO OTHER: NO

FILL IN THE BLANKS BELOW

TOTAL PILOT FLYING HOURS ________ PILOT HOURS FLOWN PAST 12 MONTHS: ________ BUSINESS ________ PLEASURE ________ TOTAL ________

For Office Use Only Admin. Code R County Code ________

SIGNATURE OF PILOT DATE

PLEASE RETURN THIS FORM AND YOUR REMITTANCE OF $4 TO:

AERONAUTICS DIVISION 3040 25th Street S. E. Salem, Oregon 97310

Phone: (503) 378-4880

Appropriate Oregon Revised Statutes a division of the are printed on the reverse side. OREGON DEPARTMENT OF TRANSPORTATION

Form #802 - 768 Rev. 8/77

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[guess: aut] 933 164-81-7876

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DB Cooper-15968