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REGISTRATION FEE $4.00 e ORS 493.050 OREGON PILOT REGISTRATION RENEWAL REMINDER REGISTRATION PERIOD FRGM 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 BIRTHS LO 1 6-43 _ Mo. Day Year RACKSTRAWs ROBERT W ° HOME PHONE: 7721245 PO BOX 352 BUSINESS PHONE*7721 756 VALLEY SPRINGS CA 95252 OREGON COUNTY(NON~-OR STATE): CALIFORNIA | FOR AIRCRAFT OWNERS ONLY AIRCRAFT OWNER:NO AIRCRAFT USED FOR BUSINESS:NeAc INSTRUMENT RATING: YES FLIGHT INSTRUCTOR: YES | FAA AIRCRAFT 4:NcA. "AIRCRAFT USED FOR PLEASURE:NAA} ***HIGHEST PILOT CERTIFICATE*** EREKEETYPE OF AIRCRAFT RAT INGER RRR REE Pad STUDENT: NGT APPLICABLE SINGLE~ENGINE-LAND: YES . GLIDERS NO PRIVATE: NOT APPLICABLE SINGLE-ENGINE-SEA: NO HELICOPTER: YES _COMMERCTAL2YES . | MULTI—ENGINE-LAND: YES BALLOON: NO ATR TRANSPORT <:NO MULTI-—ENGINE-SEA: NO OTHER: . NG ’ FILL IN THE BLANKS BELOW TOTAL PILOT FLYING HOURS For Office Use Only PILOT HOURS FLOWN PAST 12 MONTHS: Admin. Code . Cc Cod BUSINESS PLEASURE TOTAL ounty 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 “993. Appropriate Oregon Revised Statutes - a division of the Medes - Tere 4 are printed on the reverse side. : . - OREGON DEPARTMENT OF TRANSPORTATION DB Cooper-15968 . _ "acm $802- 768 Rev. 8/77 a pe f