Compare and highlight differences

Compare / EASA/ Incorporated Amendments/ Compare & Highlight Differences

AMC1 to Appendix 7 IR skill test

Available versions for ERULES-1963177438-10790

ED Decision 2011/016/R found in: Aircrew (1178/2011) Part-FCL Part-MED Part-CC Part-ARA Part-ORA Part-DTO (Dec 2024)
ED Decision 2025/002/R found in: Aircrew (1178/2011) Part-FCL Part-MED Part-CC Part-ARA Part-ORA Part-DTOPart-FCL Part-MED Part-CC Part-ARA Part-ORA Part-DTO (Nov 2025)

From

Show details Hide details

AMC1 to Appendix 7 IR skill test

ED Decision 2011/016/R

LAPL, BPL, SPL, PPL, CPL, IR SKILL TEST AND
PROFICIENCY CHECK APPLICATION AND REPORT FORM

<table border="1" cellpadding="0" cellspacing="0" width="603">
<tr>
<td colspan="9" valign="top" width="603">
APPLICATION AND REPORT FORM 
LAPL, BPL, SPL, PPL, CPL, IR SKILL TEST
 AND PROFICIENCY CHECK 
</td>
</tr>
<tr>
<td colspan="7" valign="top" width="402">
Applicant’s
 last name(s):
</td>
<td colspan="2" valign="top" width="201">
</td>
</tr>
<tr>
<td colspan="7" valign="top" width="402">
Applicant’s
 first name(s):
</td>
<td colspan="2" valign="top" width="201">
<v:group coordsize="11003,944" id="Group_x0020_4366274" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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" o:spid="_x0000_s1113">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443549" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1114" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443551" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH
70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23
jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3
VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0
r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP//
AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0
X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w
Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR
gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A
AAD//wMAUEsDBBQABgAIAAAAIQAUwB9SygAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA
FITvgv9heUIvoW5sTZHoKqWl4NVUsN4eu88kmn0bsqvGf98VBC8DwzDfMItVbxtxoc7XjhVMxikI
Yu1MzaWC7e/P6wyED8gGG8ek4EYeVsvhYIG5cVfe0KUIpYgQ9jkqqEJocym9rsiiH7uWOGYH11kM
0XalNB1eI9w28i1NP6TFmuNChS19VaRPxdkq2CXbQmfJuT1lCe3S436mD39aqZdR/z2P8jkHEagP
z8YDsTYKptP3LJvA/VQ8BHL5DwAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAA
AAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAA
FQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhABTAH1LKAAAA
5AAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD+AgAA
AAA=
" o:spid="_x0000_s1115" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443553" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1116" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443555" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1117" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape></v:group>LAPL:      A         H            B           S
</td>
</tr>
<tr>
<td colspan="7" valign="top" width="402">
Signature
 of applicant:
</td>
<td colspan="2" valign="top" width="201">
BPL:     <v:group coordsize="94488,94488" id="Group_x0020_4366319" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF
90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA
0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD
OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893
SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y
JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl
bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR
JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY
22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i
OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA
IQBmFYkwKAIAAFoFAAAOAAAAZHJzL2Uyb0RvYy54bWykVE1v2zAMvQ/YfxB0X5y0RtAZcXpY21yG
rUDbH6BI8gcgi4Kk2Mm/H8XETtpiPbQ+2BT1RPM9Ulzd7jvDeu1DC7bki9mcM20lqNbWJX95fvhx
w1mIwiphwOqSH3Tgt+vv31aDK/QVNGCU9gyD2FAMruRNjK7IsiAb3YkwA6ctblbgOxFx6etMeTFg
9M5kV/P5MhvAK+dB6hDQe3fc5GuKX1Vaxr9VFXRkpuSYW6S3p/c2vbP1ShS1F65p5SkN8YksOtFa
/OkU6k5EwXa+fReqa6WHAFWcSegyqKpWauKAbBbzN2w2HnaOuNTFULtJJpT2jU6fDiv/9Bvvntyj
RyUGV6MWtEpc9pXv0hezZHuS7DBJpveRSXT+zPMbLLHEnaNJgsoGVX93Rjb3H5zKxh9mr9IYHDZG
OHMPX+P+1AinSdJQIPdHz1pV8jy/Xi4XnFnRYY8Shp18JAthJ5FCEVCvryg0cRWF3IW40UBCi/53
iMeOVKMlmtGSezuaHvv6w452IqZzKcdksmEsD2tGK+110OtnIFQ8l2sqJKZ5Rhh7iTzV/bLsiB4x
49dR1DOW7tt/cXg/xwa7wEgDQaMo6EpUJoPoofNSQAsPrTGkoLFEepHn2J0CJ4u3im5oANOqBEu0
g6+3v4xnvUjzgZ40EjDsKxjeQ6uOfmPTOU2j5VgO7NexI5K1BXWg20R+bF0MlzoaLzAFPg2bNCEu
14Q6j8T1PwAAAP//AwBQSwMEFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAABkcnMvZG93bnJldi54
bWxMj0FPwkAQhe8m/ofNkHiTbUWNlG4JAfVETAQTwm3oDm1Dd7bpLm359y560MubTF7mzfvS+WBq
0VHrKssK4nEEgji3uuJCwdf27f4FhPPIGmvLpOBCDubZ7U2KibY9f1K38YUIIewSVFB63yRSurwk
g25sG+LgHW1r0Ie1LaRusQ/hppYPUfQsDVYcPpTY0LKk/LQ5GwXvPfaLSfzarU/H5WW/ffrYrWNS
6m40rGZBFjMQngb/dwFXhtAfslDsYM+snagVBBr/o1fvcQri8Dtllsr/ANk3AAAA//8DAFBLAQIt
ABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10u
eG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAAAAAAAAAALwEAAF9yZWxzLy5y
ZWxzUEsBAi0AFAAGAAgAAAAhAGYViTAoAgAAWgUAAA4AAAAAAAAAAAAAAAAALgIAAGRycy9lMm9E
b2MueG1sUEsBAi0AFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAAAAAAAAAAAAAAAAggQAAGRycy9k
b3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAACMBQAAAAA=
" o:spid="_x0000_s1111">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443661" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH
70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23
jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3
VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0
r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP//
AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0
X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w
Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR
gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A
AAD//wMAUEsDBBQABgAIAAAAIQABibSTywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9La8Mw
EITvhf4HsYVeTCPnZYIdJZSGQq91Amlvi7R+NNbKWEri/vuoUMhlYBjmG2a9HW0nLjT41rGC6SQF
QaydablWcNi/v6xA+IBssHNMCn7Jw3bz+LDG3Lgrf9KlDLWIEPY5KmhC6HMpvW7Iop+4njhmlRss
hmiHWpoBrxFuOzlL00xabDkuNNjTW0P6VJ6tgmNyKPUyOfenZULH9Od7pasvrdTz07grorwWIAKN
4d74R3wYBYvFPMum8HcqHgK5uQEAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA
AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA
ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQABibSTywAA
AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA
AAAA
" o:spid="_x0000_s1112" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group>             SPL: <v:group coordsize="94488,94488" id="Group_x0020_4366320" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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" o:spid="_x0000_s1109">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443663" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH
70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23
jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3
VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0
r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP//
AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0
X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w
Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR
gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A
AAD//wMAUEsDBBQABgAIAAAAIQCeF49/ygAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA
FITvBf/D8oRegm5aNUh0laIUem0U1Ntj95lEs29DdtX033cLBS8DwzDfMMt1bxtxp87XjhW8jVMQ
xNqZmksF+93naA7CB2SDjWNS8EMe1qvByxJz4x78TfcilCJC2OeooAqhzaX0uiKLfuxa4pidXWcx
RNuV0nT4iHDbyPc0zaTFmuNChS1tKtLX4mYVHJJ9oWfJrb3OEjqkl9Ncn49aqddhv11E+ViACNSH
Z+Mf8WUUTKeTLJvA36l4COTqFwAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAA
AAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAA
FQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAJ4Xj3/KAAAA
5AAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD+AgAA
AAA=
" o:spid="_x0000_s1110" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group> 
</td>
</tr>
<tr>
<td colspan="7" valign="top" width="402">
Type
 of licence*:
</td>
<td colspan="2" valign="top" width="201">
<v:group coordsize="373380,94488" id="Group_x0020_4366361" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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=
" o:spid="_x0000_s1106">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443769" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1107" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443771" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1108" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape></v:group>PPL:
 A       H         As 
 <v:group coordsize="94488,94488" id="Group_x0020_4366362" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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" o:spid="_x0000_s1104">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443773" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH
70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23
jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3
VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0
r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP//
AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0
X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w
Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR
gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A
AAD//wMAUEsDBBQABgAIAAAAIQBtLxY/ywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA
FITvBf/D8gQvQTetWiW6SqkUvDYV1Ntj95lEs29DdtX037uFgpeBYZhvmOW6s7W4UesrxwpeRykI
Yu1MxYWC3c/XcA7CB2SDtWNS8Ese1qveyxIz4+78Tbc8FCJC2GeooAyhyaT0uiSLfuQa4pidXGsx
RNsW0rR4j3Bby7c0fZcWK44LJTb0WZK+5FerYJ/scj1Nrs1lmtA+PR/n+nTQSg363WYR5WMBIlAX
no1/xNYomEzGs9kY/k7FQyBXDwAAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA
AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA
ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQBtLxY/ywAA
AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA
AAAA
" o:spid="_x0000_s1105" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group> 
</td>
</tr>
<tr>
<td colspan="7" valign="top" width="402">
Licence
 number*:
</td>
<td colspan="2" valign="top" width="201">
<v:group coordsize="373380,94488" id="_x0000_s1101" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443769" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1102" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443771" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1103" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape></v:group>CPL:
 A       H         As 
 <v:group coordsize="94488,94488" id="_x0000_s1099" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443773" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1100" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group> 
</td>
</tr>
<tr>
<td colspan="7" valign="top" width="402">
State:
</td>
<td colspan="2" valign="top" width="201">
<v:group coordsize="373380,94488" id="_x0000_s1096" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF
90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA
0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD
OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893
SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y
JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl
bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR
JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY
22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i
OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA
IQACMDWfcQIAACUIAAAOAAAAZHJzL2Uyb0RvYy54bWzsVU2P2jAQvVfqf7ByLyFAIYmAPXS7XKp2
pd39AcZxPiTHtmxD4N93PMGQhapqt+qlag7JJH6ezHvzbC/vDq0ge25so+QqSkbjiHDJVNHIahW9
PD98SCNiHZUFFUryVXTkNrpbv3+37HTOJ6pWouCGQBJp806voto5ncexZTVvqR0pzSUMlsq01MGr
qeLC0A6ytyKejMfzuFOm0EYxbi18ve8HozXmL0vO3LeytNwRsYqgNod3g/etv8frJc0rQ3XdsFMZ
9A1VtLSR8NNzqnvqKNmZ5iZV2zCjrCrdiKk2VmXZMI4cgE0yvmKzMWqnkUuVd5U+ywTSXun05rTs
635j9JN+NKBEpyvQAt88l0NpWv+EKskBJTueJeMHRxh8nC6m0xSEZTCUTTMIUVFWg+w3k1j9+UfT
ZrM09dPi8Mv4VSGdBmvYC3v7Z+yfaqo5impzYP9oSFOsokkyST6Op9l8ERFJW3Aq4shsNl3MM1+d
LwPwZ6lsbkG1X9UpQ5K9TDd8ac521m24Qrnp/ot1qGJVhIjWIWIHGUID7v6przV1fp6v0Yekgx71
ddQh8mOt2vNnhSh36VmP7NtyQQg5RJ6y+d4PSAVMeGrMesGiR6DZYTw8exyYKdhsgGFCWd4X46mg
Wc70ADcUUKqHRghUUEgkncxmYFEK+4uRBa5Tq0RTeJinbU21/SQM2VO/S+B18uMrGKxGWfQ1COnn
cdxg+naAZ4MjfLRVxRHXFH4H+/YG+vs+BqLX/l0kv+XfySJNs8mlC8DztGpPLcS1Puh32CeGPfhv
4n/TxLg1w1mEC/B0bvrDbvgO8fB0X38HAAD//wMAUEsDBBQABgAIAAAAIQDzOPE63wAAAAwBAAAP
AAAAZHJzL2Rvd25yZXYueG1sTE9Nb8IwDL1P2n+IjLTbSMsEYqUpQuzjhCYNJk3cTGPaiiapmtCW
fz/3NC72s579/F66HkwtOmp95ayCeBqBIJs7XdlCwc/h43kJwge0GmtnScGNPKyzx4cUE+16+03d
PhSCRaxPUEEZQpNI6fOSDPqpa8gyd3atwcBjW0jdYs/ippazKFpIg5XlDyU2tC0pv+yvRsFnj/3m
JX7vdpfz9nY8zL9+dzEp9TQZ3lZcNisQgYbwfwFjBvYPGRs7uavVXtQK5osZb3LnWCMdj+DE4HUJ
MkvlfYjsDwAA//8DAFBLAQItABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAA
AABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAA
AAAAAAAALwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAAIwNZ9xAgAAJQgAAA4AAAAAAAAA
AAAAAAAALgIAAGRycy9lMm9Eb2MueG1sUEsBAi0AFAAGAAgAAAAhAPM48TrfAAAADAEAAA8AAAAA
AAAAAAAAAAAAywQAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAADXBQAAAAA=
">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443769" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1097" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443771" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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==
" o:spid="_x0000_s1098" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape></v:group>IR:   A         H         As 
 <v:group coordsize="94488,94488" id="_x0000_s1094" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF
90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA
0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD
OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893
SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y
JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl
bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR
JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY
22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i
OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA
IQCgqomhKgIAAFYFAAAOAAAAZHJzL2Uyb0RvYy54bWykVM1u2zAMvg/YOwi6L05So+2MOD2say7D
VqDdAyiS/APIoiApcfL2o5jYTlush9YHmaIoit/Hn9XdoTNsr31owZZ8MZtzpq0E1dq65H+fH77d
chaisEoYsLrkRx343frrl1XvCr2EBozSnqETG4relbyJ0RVZFmSjOxFm4LTFwwp8JyJufZ0pL3r0
3plsOZ9fZz145TxIHQJq70+HfE3+q0rL+Keqgo7MlBxji7R6WrdpzdYrUdReuKaV5zDEB6LoRGvx
0dHVvYiC7Xz7xlXXSg8BqjiT0GVQVa3UhAHRLOav0Gw87BxhqYu+diNNSO0rnj7sVv7eb7x7co8e
mehdjVzQLmE5VL5Lf4ySHYiy40iZPkQmUfk9z28xxRJPTiIRKhtk/c0d2fx851Y2PJi9CKN3WBhh
wh4+h/2pEU4TpaFA7I+etarky2vOrOiwPumc5fnVzc1VKo70PNqNBIUiIFefYWfEKQq5C3GjgUgW
+18hnqpRDZJoBkke7CB6rOl3q9mJmO6lGJPI+iE1rBmkdNbBXj8DWcUpVWMSMczJwthLy3POL1OO
1oPN8HfkdbKlXvuvHfbmUFwXNtJA0EgKqhKUUSB4qLwk0MJDawwxaCyBXuQ5VqbAqeKtou4MYFqV
zBLs4OvtD+PZXqTZQF/KOLp9YYY9aNVJb2y6p2msnNKBtTpURJK2oI7USaTHskV3qZqxecnxedCk
6XC5J6tpHK7/AQAA//8DAFBLAwQUAAYACAAAACEA3gPSjN0AAAAIAQAADwAAAGRycy9kb3ducmV2
LnhtbEyPQU/CQBCF7yb+h82QeJNtRY2UbgkB9URMBBPCbegObUN3tukubfn3LnrQy5tMXubN+9L5
YGrRUesqywricQSCOLe64kLB1/bt/gWE88gaa8uk4EIO5tntTYqJtj1/UrfxhQgh7BJUUHrfJFK6
vCSDbmwb4uAdbWvQh7UtpG6xD+Gmlg9R9CwNVhw+lNjQsqT8tDkbBe899otJ/NqtT8flZb99+tit
Y1LqbjSsZkEWMxCeBv93AVeG0B+yUOxgz6ydqBUEGv+jV+9xCuLwO2WWyv8A2TcAAAD//wMAUEsB
Ai0AFAAGAAgAAAAhALaDOJL+AAAA4QEAABMAAAAAAAAAAAAAAAAAAAAAAFtDb250ZW50X1R5cGVz
XS54bWxQSwECLQAUAAYACAAAACEAOP0h/9YAAACUAQAACwAAAAAAAAAAAAAAAAAvAQAAX3JlbHMv
LnJlbHNQSwECLQAUAAYACAAAACEAoKqJoSoCAABWBQAADgAAAAAAAAAAAAAAAAAuAgAAZHJzL2Uy
b0RvYy54bWxQSwECLQAUAAYACAAAACEA3gPSjN0AAAAIAQAADwAAAAAAAAAAAAAAAACEBAAAZHJz
L2Rvd25yZXYueG1sUEsFBgAAAAAEAAQA8wAAAI4FAAAAAA==
">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443773" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1095" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group> 
</td>
</tr>
<tr>
<td valign="top" width="40">
1 
</td>
<td colspan="8" valign="top" width="562">
Details of the flight
</td>
</tr>
<tr>
<td colspan="5" valign="top" width="311">
Group,
 class, type of aircraft:
</td>
<td colspan="4" valign="top" width="292">
Registration:
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="165">
Aerodrome or site: 
</td>
<td colspan="3" valign="top" width="146">
Take-off time: 
</td>
<td colspan="3" valign="top" width="146">
Landing time: 
</td>
<td valign="top" width="146">
Flight time: 
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="165">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td valign="top" width="146">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="165">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td valign="top" width="146">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="165">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td valign="top" width="146">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="165">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td valign="top" width="146">
</td>
</tr>
<tr>
<td colspan="2" valign="top" width="165">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td colspan="3" valign="top" width="146">
</td>
<td valign="top" width="146">
Total
 flight time: 
</td>
</tr>
<tr>
<td valign="top" width="40">
2 
</td>
<td colspan="8" valign="top" width="562">
Result of the test 
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
Skill
 test details: 
</td>
</tr>
<tr>
<td colspan="3" valign="top" width="173">
Pass     <v:group coordsize="94488,94488" id="Group_x0020_4367171" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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" o:spid="_x0000_s1092">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_444585" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH
70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23
jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3
VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0
r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP//
AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0
X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w
Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR
gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A
AAD//wMAUEsDBBQABgAIAAAAIQAGIYKLxwAAAOAAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI/BasJA
EIbvQt9hmUIvoW4qKBJdpbQUejUK2tuwOyap2dmQXTW+vXMQvAz8DP838y3Xg2/VhfrYBDbwMc5B
EdvgGq4M7LY/73NQMSE7bAOTgRtFWK9eRkssXLjyhi5lqpRAOBZooE6pK7SOtiaPcRw6YtkdQ+8x
Sewr7Xq8Cty3epLnM+2xYblQY0dfNdlTefYG9tmutNPs3J2mGe3z/7+5PR6sMW+vw/dCxucCVKIh
PRsPxK8zMJGPRUhkQK/uAAAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAAAAA
AAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAAFQEA
AAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAAYhgovHAAAA4AAA
AA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD7AgAAAAA=
" o:spid="_x0000_s1093" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group>
</td>
<td colspan="3" valign="top" width="146">
Fail       <v:group coordsize="94488,94488" id="_x0000_s1090" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_444585" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1091" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group> 
</td>
<td colspan="3" valign="top" width="284">
Partial
 pass     <v:group coordsize="94488,94488" id="Group_x0020_4367193" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF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" o:spid="_x0000_s1088">
<v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_444587" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH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" o:spid="_x0000_s1089" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt">
</v:shape>
</v:group>
</td>
</tr>
<tr>
<td valign="top" width="40">
3 
</td>
<td colspan="8" valign="top" width="562">
Remarks 
 
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
</td>
</tr>
<tr>
<td colspan="9" valign="top" width="603">
Location
 and date: 
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="297">
Examiner’s
 certificate number *: 
</td>
<td colspan="5" valign="top" width="306">
Type
 and number of licence: 
</td>
</tr>
<tr>
<td colspan="4" valign="top" width="297">
Signature
 of examiner: 
</td>
<td colspan="5" valign="top" width="306">
Name(s)
 in capital letters: 
</td>
</tr>
<tr height="0">
</tr>
</table>

\* if applicable

AMC1 to Appendix 7 IR skill test

ED Decision 2011/016/R

LAPL, BPL, SPL, PPL, CPL, IR SKILL TEST AND PROFICIENCY CHECK APPLICATION AND REPORT FORM

<table border="1" cellpadding="0" cellspacing="0" width="603"><tr><td colspan="9" valign="top" width="603">APPLICATION AND REPORT FORM LAPL, BPL, SPL, PPL, CPL, IR SKILL TEST AND PROFICIENCY CHECK </td></tr><tr><td colspan="7" valign="top" width="402">Applicant’s last name(s):</td><td colspan="2" valign="top" width="201"></td></tr><tr><td colspan="7" valign="top" width="402">Applicant’s first name(s):</td><td colspan="2" valign="top" width="201"><v:group coordsize="11003,944" id="Group_x0020_4366274" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQBZzFLWrgIAALoNAAAOAAAAZHJzL2Uyb0RvYy54bWzsV01z2yAQvXem/4HRvZFsy4mkiZ1D0+TS aTuT9AcQhD5mEDBALOffd1kJW4nTNklncql9QAiW1b63jzWcX2w7QTbc2FbJVTQ7SSLCJVNlK+tV 9PP26lMWEeuoLKlQkq+iB26ji/XHD+e9LvhcNUqU3BBwIm3R61XUOKeLOLas4R21J0pzCZOVMh11 8GrquDS0B++diOdJchr3ypTaKMathdHLYTJao/+q4sx9ryrLHRGrCGJz2Bps73wbr89pURuqm5aN YdA3RNHRVsJHd64uqaPk3rQHrrqWGWVV5U6Y6mJVVS3jiAHQzJInaK6NuteIpS76Wu9oAmqf8PRm t+zb5troG/3DABO9roELfPNYtpXp/BOiJFuk7GFHGd86wmBwluR5NgdmGczlizwbKWUN8H6wijVf wrpZkizmZ+O6NM0yn4o4fDR+FEqvQRx2j9/+G/6bhmqOtNoC8P8wpC1XUZoulmkeEUk70CnakHEM qUHbHVG2sMDZS1nKEeDA0QFWWrB76665QrLp5qt1gyrL0KNN6LGtDF0D2v6jqjV1fp2P0XdJDwka 4mhCz891asNvFVq5fcIGyyElewshp5ajN5/4CahgE54ave5tUSCQ6DAfnoMdKCmIbGLDhLJ8CMZD QaHs4IHdlECprlohkEEhEfQsTUFnFKqLkSXuUqtEW3ozD9ua+u6zMGRDfY3A36jFR2awF2U5xCCk X8exvAzpAL0GRfjenSofcEfhOEjX76130vBydqhhGIPIfQig979reH6WZfl8nwnAOm7bMY242Sc5 D5VimoejkI9CfsF/3O+L8XLxjJAXrxLyWZKdnk5KylHI+zp/rMjvVpGXzwh5+Sohw2lpmaVHJY/n j8dnhv9eyXhahgsCnovGy4y/gUzfoT+9cq1/AQAA//8DAFBLAwQUAAYACAAAACEAlR2zj+QAAAAM AQAADwAAAGRycy9kb3ducmV2LnhtbEyPT2+CQBDF7036HTbTpLe6gJZaZDHG/jmZJlUT09sIIxDZ XcKugN++46m9TDJ5b968X7ocdSN66lxtjYJwEoAgk9uiNqWC/e7jaQ7CeTQFNtaQgis5WGb3dykm hR3MN/VbXwoOMS5BBZX3bSKlyyvS6Ca2JcPayXYaPa9dKYsOBw7XjYyCIJYaa8MfKmxpXVF+3l60 gs8Bh9U0fO8359P6+rN7/jpsQlLq8WF8W/BYLUB4Gv3fBdwYuD9kXOxoL6ZwolHwOmMer2Aag2A5 il8iEEf2zWcgs1T+h8h+AQAA//8DAFBLAQItABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAA AAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEA AAsAAAAAAAAAAAAAAAAALwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAFnMUtauAgAAug0A AA4AAAAAAAAAAAAAAAAALgIAAGRycy9lMm9Eb2MueG1sUEsBAi0AFAAGAAgAAAAhAJUds4/kAAAA DAEAAA8AAAAAAAAAAAAAAAAACAUAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAAAZBgAA AAA= " o:spid="_x0000_s1113"><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443549" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQBvb4WJywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvhf6H5RV6CbppmxSNriKK0GtTQb09dp9JavZtyK6a/vtuoeBlYBjmG2a+HGwrrtT7xrGCl3EK glg703ClYPe1HU1A+IBssHVMCn7Iw3Lx+DDHwrgbf9K1DJWIEPYFKqhD6Aopva7Joh+7jjhmJ9db DNH2lTQ93iLctvI1Td+lxYbjQo0drWvS5/JiFeyTXanz5NKd84T26fdxok8HrdTz07CZRVnNQAQa wr3xj/gwCrLsLc+m8HcqHgK5+AUAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQBvb4WJywAA AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA AAAA " o:spid="_x0000_s1114" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443551" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQAUwB9SygAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvgv9heUIvoW5sTZHoKqWl4NVUsN4eu88kmn0bsqvGf98VBC8DwzDfMItVbxtxoc7XjhVMxikI Yu1MzaWC7e/P6wyED8gGG8ek4EYeVsvhYIG5cVfe0KUIpYgQ9jkqqEJocym9rsiiH7uWOGYH11kM 0XalNB1eI9w28i1NP6TFmuNChS19VaRPxdkq2CXbQmfJuT1lCe3S436mD39aqZdR/z2P8jkHEagP z8YDsTYKptP3LJvA/VQ8BHL5DwAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAA AAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAA FQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhABTAH1LKAAAA 5AAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD+AgAA AAA= " o:spid="_x0000_s1115" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443553" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQCLXiS+ygAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvQv/D8gpeQt1UTZHoKqWl4LVRUG+P3WcSzb4N2VXTf+8WBC8DwzDfMItVbxtxpc7XjhW8j1IQ xNqZmksF283P2wyED8gGG8ek4I88rJYvgwXmxt34l65FKEWEsM9RQRVCm0vpdUUW/ci1xDE7us5i iLYrpenwFuG2keM0/ZAWa44LFbb0VZE+FxerYJdsC50ll/acJbRLT4eZPu61UsPX/nse5XMOIlAf no0HYm0UTKeTLJvA/6l4COTyDgAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAA AAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAA FQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAIteJL7KAAAA 5AAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD+AgAA AAA= " o:spid="_x0000_s1116" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443555" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQBr+xlRywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9BawIx FITvQv9DeAUvS822NUVWo5QWwWtXwfb2SJ67Wzcvyybq+u+bguBlYBjmG2axGlwrztSHxrOG50kO gth423ClYbddP81AhIhssfVMGq4UYLV8GC2wsP7CX3QuYyUShEOBGuoYu0LKYGpyGCa+I07ZwfcO Y7J9JW2PlwR3rXzJ8zfpsOG0UGNHHzWZY3lyGvbZrjQqO3VHldE+//2ZmcO30Xr8OHzOk7zPQUQa 4r1xQ2yshun0VSkF/6fSIZDLPwAAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQBr+xlRywAA AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA AAAA " o:spid="_x0000_s1117" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group>LAPL: A H B S</td></tr><tr><td colspan="7" valign="top" width="402">Signature of applicant:</td><td colspan="2" valign="top" width="201">BPL: <v:group coordsize="94488,94488" id="Group_x0020_4366319" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQBmFYkwKAIAAFoFAAAOAAAAZHJzL2Uyb0RvYy54bWykVE1v2zAMvQ/YfxB0X5y0RtAZcXpY21yG rUDbH6BI8gcgi4Kk2Mm/H8XETtpiPbQ+2BT1RPM9Ulzd7jvDeu1DC7bki9mcM20lqNbWJX95fvhx w1mIwiphwOqSH3Tgt+vv31aDK/QVNGCU9gyD2FAMruRNjK7IsiAb3YkwA6ctblbgOxFx6etMeTFg 9M5kV/P5MhvAK+dB6hDQe3fc5GuKX1Vaxr9VFXRkpuSYW6S3p/c2vbP1ShS1F65p5SkN8YksOtFa /OkU6k5EwXa+fReqa6WHAFWcSegyqKpWauKAbBbzN2w2HnaOuNTFULtJJpT2jU6fDiv/9Bvvntyj RyUGV6MWtEpc9pXv0hezZHuS7DBJpveRSXT+zPMbLLHEnaNJgsoGVX93Rjb3H5zKxh9mr9IYHDZG OHMPX+P+1AinSdJQIPdHz1pV8jy/Xi4XnFnRYY8Shp18JAthJ5FCEVCvryg0cRWF3IW40UBCi/53 iMeOVKMlmtGSezuaHvv6w452IqZzKcdksmEsD2tGK+110OtnIFQ8l2sqJKZ5Rhh7iTzV/bLsiB4x 49dR1DOW7tt/cXg/xwa7wEgDQaMo6EpUJoPoofNSQAsPrTGkoLFEepHn2J0CJ4u3im5oANOqBEu0 g6+3v4xnvUjzgZ40EjDsKxjeQ6uOfmPTOU2j5VgO7NexI5K1BXWg20R+bF0MlzoaLzAFPg2bNCEu 14Q6j8T1PwAAAP//AwBQSwMEFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAABkcnMvZG93bnJldi54 bWxMj0FPwkAQhe8m/ofNkHiTbUWNlG4JAfVETAQTwm3oDm1Dd7bpLm359y560MubTF7mzfvS+WBq 0VHrKssK4nEEgji3uuJCwdf27f4FhPPIGmvLpOBCDubZ7U2KibY9f1K38YUIIewSVFB63yRSurwk g25sG+LgHW1r0Ie1LaRusQ/hppYPUfQsDVYcPpTY0LKk/LQ5GwXvPfaLSfzarU/H5WW/ffrYrWNS 6m40rGZBFjMQngb/dwFXhtAfslDsYM+snagVBBr/o1fvcQri8Dtllsr/ANk3AAAA//8DAFBLAQIt ABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10u eG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAAAAAAAAAALwEAAF9yZWxzLy5y ZWxzUEsBAi0AFAAGAAgAAAAhAGYViTAoAgAAWgUAAA4AAAAAAAAAAAAAAAAALgIAAGRycy9lMm9E b2MueG1sUEsBAi0AFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAAAAAAAAAAAAAAAAggQAAGRycy9k b3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAACMBQAAAAA= " o:spid="_x0000_s1111"><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443661" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQABibSTywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9La8Mw EITvhf4HsYVeTCPnZYIdJZSGQq91Amlvi7R+NNbKWEri/vuoUMhlYBjmG2a9HW0nLjT41rGC6SQF QaydablWcNi/v6xA+IBssHNMCn7Jw3bz+LDG3Lgrf9KlDLWIEPY5KmhC6HMpvW7Iop+4njhmlRss hmiHWpoBrxFuOzlL00xabDkuNNjTW0P6VJ6tgmNyKPUyOfenZULH9Od7pasvrdTz07grorwWIAKN 4d74R3wYBYvFPMum8HcqHgK5uQEAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQABibSTywAA AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA AAAA " o:spid="_x0000_s1112" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group> SPL: <v:group coordsize="94488,94488" id="Group_x0020_4366320" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQC8HndmKAIAAFoFAAAOAAAAZHJzL2Uyb0RvYy54bWykVE1v2zAMvQ/YfxB0X5y0RtAZcXroRy7D VqDdD1Ak+QOQRUFS7OTfj2JiJ22xHlofbIp6ovkeKa5u951hvfahBVvyxWzOmbYSVGvrkv99efxx w1mIwiphwOqSH3Tgt+vv31aDK/QVNGCU9gyD2FAMruRNjK7IsiAb3YkwA6ctblbgOxFx6etMeTFg 9M5kV/P5MhvAK+dB6hDQe3/c5GuKX1Vaxj9VFXRkpuSYW6S3p/c2vbP1ShS1F65p5SkN8YksOtFa /OkU6l5EwXa+fReqa6WHAFWcSegyqKpWauKAbBbzN2w2HnaOuNTFULtJJpT2jU6fDit/9xvvnt2T RyUGV6MWtEpc9pXv0hezZHuS7DBJpveRSXT+zPMbLLHEnaNJgsoGVX93RjYPH5zKxh9mr9IYHDZG OHMPX+P+3AinSdJQIPcnz1pV8jy/Xi6vObOiwx4lDDv5SBbCTiKFIqBeX1Fo4ioKuQtxo4GEFv2v EI8dqUZLNKMl93Y0Pfb1hx3tREznUo7JZMNYHtaMVtrroNcvQKh4LtdUSEzzjDD2Enmq+2XZET1i xq+jqGcs3bf/4vB+jg12gZEGgkZR0JWoTAbRQ+elgBYeW2NIQWOJ9CLPsTsFThZvFd3QAKZVCZZo B19v74xnvUjzgZ40EjDsKxjeQ6uOfmPTOU2j5VgO7NexI5K1BXWg20R+bF0MlzoaLzAFPg2bNCEu 14Q6j8T1PwAAAP//AwBQSwMEFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAABkcnMvZG93bnJldi54 bWxMj0FPwkAQhe8m/ofNkHiTbUWNlG4JAfVETAQTwm3oDm1Dd7bpLm359y560MubTF7mzfvS+WBq 0VHrKssK4nEEgji3uuJCwdf27f4FhPPIGmvLpOBCDubZ7U2KibY9f1K38YUIIewSVFB63yRSurwk g25sG+LgHW1r0Ie1LaRusQ/hppYPUfQsDVYcPpTY0LKk/LQ5GwXvPfaLSfzarU/H5WW/ffrYrWNS 6m40rGZBFjMQngb/dwFXhtAfslDsYM+snagVBBr/o1fvcQri8Dtllsr/ANk3AAAA//8DAFBLAQIt ABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10u eG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAAAAAAAAAALwEAAF9yZWxzLy5y ZWxzUEsBAi0AFAAGAAgAAAAhALwed2YoAgAAWgUAAA4AAAAAAAAAAAAAAAAALgIAAGRycy9lMm9E b2MueG1sUEsBAi0AFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAAAAAAAAAAAAAAAAggQAAGRycy9k b3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAACMBQAAAAA= " o:spid="_x0000_s1109"><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443663" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQCeF49/ygAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvBf/D8oRegm5aNUh0laIUem0U1Ntj95lEs29DdtX033cLBS8DwzDfMMt1bxtxp87XjhW8jVMQ xNqZmksF+93naA7CB2SDjWNS8EMe1qvByxJz4x78TfcilCJC2OeooAqhzaX0uiKLfuxa4pidXWcx RNuV0nT4iHDbyPc0zaTFmuNChS1tKtLX4mYVHJJ9oWfJrb3OEjqkl9Ncn49aqddhv11E+ViACNSH Z+Mf8WUUTKeTLJvA36l4COTqFwAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAA AAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAA FQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAJ4Xj3/KAAAA 5AAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD+AgAA AAA= " o:spid="_x0000_s1110" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group></td></tr><tr><td colspan="7" valign="top" width="402">Type of licence*:</td><td colspan="2" valign="top" width="201"><v:group coordsize="373380,94488" id="Group_x0020_4366361" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQDG+WekbgIAACUIAAAOAAAAZHJzL2Uyb0RvYy54bWzsVctu2zAQvBfoPxC61/JDiGXBcg5N40vR Bkj6ATRFPQCKJEjasv++y5VoK3HRBgnQQ1EdpCW5XO3MzpLr22MryIEb2yiZR7PJNCJcMlU0ssqj H0/3n9KIWEdlQYWSPI9O3Ea3m48f1p3O+FzVShTcEAgibdbpPKqd01kcW1bzltqJ0lzCYqlMSx0M TRUXhnYQvRXxfDq9iTtlCm0U49bC7F2/GG0wflly5r6XpeWOiDyC3By+Db53/h1v1jSrDNV1w4Y0 6BuyaGkj4afnUHfUUbI3zVWotmFGWVW6CVNtrMqyYRwxAJrZ9AWarVF7jViqrKv0mSag9gVPbw7L vh22Rj/qBwNMdLoCLnDksRxL0/ovZEmOSNnpTBk/OsJgcrFcLFIglsHSarECExllNdB+tYnVX361 LUnS1G+Lwy/jZ4l0GqRhL+jt+9A/1lRzJNVmgP7BkKbIoyRZLG9WEZG0BZWiDxnmkBj0PdNkMwuM vZajFQLsKbrCSjO2t27LFVJND1+tQwarIli0DhY7ymAaUPZvNa2p8/t8jt4kHdSnz6MOll9r1YE/ KfRyl3r1nn1JLh5Cjj2HaL7uI1DBJ3w1Rr34oj6g0GE9fHs/EFKQ2MiHCWV5n4yHgkI5wwO/MYFS 3TdCIINCIuhZkoA8KZwtRhbYo1aJpvBuHrY11e6zMORA/QmBz6DFZ27QibLocxDS7+N4uPTlAL0G RXhrp4oT9hPOg3R9Z/0lDS9n1xqGOcjcpwB6/7OG58s0Xc0vlQCsQ9cOZcReH9U8nBPjOvwX8r8p ZDya4S7CJhzuTX/Zjcdgj2/3zU8AAAD//wMAUEsDBBQABgAIAAAAIQDzOPE63wAAAAwBAAAPAAAA ZHJzL2Rvd25yZXYueG1sTE9Nb8IwDL1P2n+IjLTbSMsEYqUpQuzjhCYNJk3cTGPaiiapmtCWfz/3 NC72s579/F66HkwtOmp95ayCeBqBIJs7XdlCwc/h43kJwge0GmtnScGNPKyzx4cUE+16+03dPhSC RaxPUEEZQpNI6fOSDPqpa8gyd3atwcBjW0jdYs/ippazKFpIg5XlDyU2tC0pv+yvRsFnj/3mJX7v dpfz9nY8zL9+dzEp9TQZ3lZcNisQgYbwfwFjBvYPGRs7uavVXtQK5osZb3LnWCMdj+DE4HUJMkvl fYjsDwAA//8DAFBLAQItABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAAAABb Q29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAAAAAA AAAALwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAMb5Z6RuAgAAJQgAAA4AAAAAAAAAAAAA AAAALgIAAGRycy9lMm9Eb2MueG1sUEsBAi0AFAAGAAgAAAAhAPM48TrfAAAADAEAAA8AAAAAAAAA AAAAAAAAyAQAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAADUBQAAAAA= " o:spid="_x0000_s1106"><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443769" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQCJHrcIzAAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvhf6H5RV6CXVjNWqjq0hLoVejYL09dp9JavZtyK4a/323UPAyMAzzDbNY9bYRF+p87VjBcJCC INbO1Fwq2G0/X2YgfEA22DgmBTfysFo+PiwwN+7KG7oUoRQRwj5HBVUIbS6l1xVZ9APXEsfs6DqL IdqulKbDa4TbRr6m6URarDkuVNjSe0X6VJytgn2yK3SWnNtTltA+/TnM9PFbK/X81H/Mo6znIAL1 4d74R3wZBePxaDp5g79T8RDI5S8AAAD//wMAUEsBAi0AFAAGAAgAAAAhANvh9svuAAAAhQEAABMA AAAAAAAAAAAAAAAAAAAAAFtDb250ZW50X1R5cGVzXS54bWxQSwECLQAUAAYACAAAACEAWvQsW78A AAAVAQAACwAAAAAAAAAAAAAAAAAfAQAAX3JlbHMvLnJlbHNQSwECLQAUAAYACAAAACEAiR63CMwA AADkAAAADwAAAAAAAAAAAAAAAAAHAgAAZHJzL2Rvd25yZXYueG1sUEsFBgAAAAADAAMAtwAAAAAD AAAAAA== " o:spid="_x0000_s1107" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443771" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQDysS3TywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvhf6H5RW8hLrRqgnRVUpLoddGwXp77D6TaPZtyK6a/vtuoeBlYBjmG2a1GWwrrtT7xrGCyTgF QaydabhSsNt+POcgfEA22DomBT/kYbN+fFhhYdyNv+hahkpECPsCFdQhdIWUXtdk0Y9dRxyzo+st hmj7SpoebxFuWzlN04W02HBcqLGjt5r0ubxYBftkV+p5cunO84T26emQ6+O3Vmr0NLwvo7wuQQQa wr3xj/g0CmazlyybwN+peAjk+hcAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQDysS3TywAA AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA AAAA " o:spid="_x0000_s1108" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group>PPL: A H As <v:group coordsize="94488,94488" id="Group_x0020_4366362" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQAtrV0jKAIAAFoFAAAOAAAAZHJzL2Uyb0RvYy54bWykVE1v2zAMvQ/YfxB0b5y0xtoZcXpo11yG rUDbH6BI8gcgi4KkxMm/H0XHTtpiPbQ+2BT1RPM9Ulze7jvDdtqHFmzJF7M5Z9pKUK2tS/7y/HBx w1mIwiphwOqSH3Tgt6vv35a9K/QlNGCU9gyD2FD0ruRNjK7IsiAb3YkwA6ctblbgOxFx6etMedFj 9M5kl/P5j6wHr5wHqUNA7/2wyVcUv6q0jH+rKujITMkxt0hvT+9NemerpShqL1zTymMa4hNZdKK1 +NMp1L2Igm19+y5U10oPAao4k9BlUFWt1MQB2Szmb9isPWwdcamLvnaTTCjtG50+HVb+2a29e3KP HpXoXY1a0Cpx2Ve+S1/Mku1JssMkmd5HJtH5M89vsMQSdwaTBJUNqv7ujGx+fXAqG3+YvUqjd9gY 4cQ9fI37UyOcJklDgdwfPWtVyfP86vr6ijMrOuxRwrCjj2Qh7CRSKALq9RWFJq6ikNsQ1xpIaLH7 HeLQkWq0RDNacm9H02Nff9jRTsR0LuWYTNaP5WHNaKW9Dnb6GQgVT+WaColpnhDGniOPdT8vO6JH zPh1FPWEpfv2Xxzez7HBzjDSQNAoCroSlckgeug8F9DCQ2sMKWgskV7kOXanwMniraIbGsC0KsES 7eDrzZ3xbCfSfKAnjQQM+wqG99CqwW9sOqdptAzlwH4dOyJZG1AHuk3kx9bFcKmj8QJT4OOwSRPi fE2o00hc/QMAAP//AwBQSwMEFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAABkcnMvZG93bnJldi54 bWxMj0FPwkAQhe8m/ofNkHiTbUWNlG4JAfVETAQTwm3oDm1Dd7bpLm359y560MubTF7mzfvS+WBq 0VHrKssK4nEEgji3uuJCwdf27f4FhPPIGmvLpOBCDubZ7U2KibY9f1K38YUIIewSVFB63yRSurwk g25sG+LgHW1r0Ie1LaRusQ/hppYPUfQsDVYcPpTY0LKk/LQ5GwXvPfaLSfzarU/H5WW/ffrYrWNS 6m40rGZBFjMQngb/dwFXhtAfslDsYM+snagVBBr/o1fvcQri8Dtllsr/ANk3AAAA//8DAFBLAQIt ABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10u eG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAAAAAAAAAALwEAAF9yZWxzLy5y ZWxzUEsBAi0AFAAGAAgAAAAhAC2tXSMoAgAAWgUAAA4AAAAAAAAAAAAAAAAALgIAAGRycy9lMm9E b2MueG1sUEsBAi0AFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAAAAAAAAAAAAAAAAggQAAGRycy9k b3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAACMBQAAAAA= " o:spid="_x0000_s1104"><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443773" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQBtLxY/ywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvBf/D8gQvQTetWiW6SqkUvDYV1Ntj95lEs29DdtX037uFgpeBYZhvmOW6s7W4UesrxwpeRykI Yu1MxYWC3c/XcA7CB2SDtWNS8Ese1qveyxIz4+78Tbc8FCJC2GeooAyhyaT0uiSLfuQa4pidXGsx RNsW0rR4j3Bby7c0fZcWK44LJTb0WZK+5FerYJ/scj1Nrs1lmtA+PR/n+nTQSg363WYR5WMBIlAX no1/xNYomEzGs9kY/k7FQyBXDwAAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQBtLxY/ywAA AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA AAAA " o:spid="_x0000_s1105" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group></td></tr><tr><td colspan="7" valign="top" width="402">Licence number*:</td><td colspan="2" valign="top" width="201"><v:group coordsize="373380,94488" id="_x0000_s1101" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQCNDLwldQIAACwIAAAOAAAAZHJzL2Uyb0RvYy54bWzsVU2PmzAQvVfqf7C4N4RAEkBJ9tDt5lK1 K+3uD3CM+ZCMbdlOSP59x0NI2A9V7Va9VOUAA34e5r15tlc3x1aQAze2UXIdRJNpQLhkqmhktQ6e Hu8+pQGxjsqCCiX5OjhxG9xsPn5YdTrnM1UrUXBDIIm0eafXQe2czsPQspq31E6U5hIGS2Va6uDV VGFhaAfZWxHOptNF2ClTaKMYtxa+3vaDwQbzlyVn7ntZWu6IWAdQm8O7wfvO38PNiuaVobpu2LkM +o4qWtpI+Okl1S11lOxN8ypV2zCjrCrdhKk2VGXZMI4cgE00fcFma9ReI5cq7yp9kQmkfaHTu9Oy b4et0Q/63oASna5AC3zzXI6laf0TqiRHlOx0kYwfHWHwMV7GcQrCMhjK4gxCVJTVIPurSaz+8ta0 JElTPy0cfhk+K6TTYA17ZW//jP1DTTVHUW0O7O8NaQpw7iJLo0UczQMiaQtGRRhJkni5yHxxvgqA X5SyuQXRflWmDDn2Kr2iS3O2t27LFapND1+tQxGrYohoPUTsKIfQgLl/amtNnZ/na/Qh6aBFfR31 EPmxVh34o0KUu7asR/ZduSKEHCPP2XzrR6QGzPDUmPWKRYtAr4fx4dnjwEuDy0YYJpTlfTGeCnrl Qg9wYwGlumuEQAWFRNJRkoBDKWwvRha4TK0STeFhnrY11e6zMORA/SaB19mOz2CwGGXR1yCkn8dx f+nbAZYdHOGjnSpOuKTwO7i3N9Dft3GUTOfzLF684eNl9Fs+ni3TNJtduwF8z4v33Epc8qO+D9vF uBf/zfxvmhl3aDiScCGej09/5o3fIR4f8psfAAAA//8DAFBLAwQUAAYACAAAACEA8zjxOt8AAAAM AQAADwAAAGRycy9kb3ducmV2LnhtbExPTW/CMAy9T9p/iIy020jLBGKlKULs44QmDSZN3Exj2oom qZrQln8/9zQu9rOe/fxeuh5MLTpqfeWsgngagSCbO13ZQsHP4eN5CcIHtBprZ0nBjTyss8eHFBPt evtN3T4UgkWsT1BBGUKTSOnzkgz6qWvIMnd2rcHAY1tI3WLP4qaWsyhaSIOV5Q8lNrQtKb/sr0bB Z4/95iV+73aX8/Z2PMy/fncxKfU0Gd5WXDYrEIGG8H8BYwb2DxkbO7mr1V7UCuaLGW9y51gjHY/g xOB1CTJL5X2I7A8AAP//AwBQSwECLQAUAAYACAAAACEAtoM4kv4AAADhAQAAEwAAAAAAAAAAAAAA AAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAA AAAAAAAAAAAAAC8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQCNDLwldQIAACwIAAAOAAAA AAAAAAAAAAAAAC4CAABkcnMvZTJvRG9jLnhtbFBLAQItABQABgAIAAAAIQDzOPE63wAAAAwBAAAP AAAAAAAAAAAAAAAAAM8EAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAQABADzAAAA2wUAAAAA "><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443769" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQDOjFGVzQAAAOcAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9BS8NA FITvgv9heYKXYDdREmLabSkVwatpofX22H1NYrNvQ3bbxn/vCkIvA8Mw3zCL1WR7caHRd44VZLMU BLF2puNGwW77/lSC8AHZYO+YFPyQh9Xy/m6BlXFX/qRLHRoRIewrVNCGMFRSet2SRT9zA3HMjm60 GKIdG2lGvEa47eVzmhbSYsdxocWBNi3pU322CvbJrtZ5ch5OeUL79Pur1MeDVurxYXqbR1nPQQSa wq3xj/gw8UPxWmbFS5bD36/oQS5/AQAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAAT AAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/ AAAAFQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAM6MUZXN AAAA5wAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAAB AwAAAAA= " o:spid="_x0000_s1102" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443771" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQBwj4TGzgAAAOgAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI/BSgMx EIbvgu8QRvCy2KRqSrttWkQRvLoWam9DMt1du5ksm7Rd394IgpeBmZ//G77VZvSdONMQ28AGphMF gtgG13JtYPvxejcHEROywy4wGfimCJv19dUKSxcu/E7nKtUiQziWaKBJqS+ljLYhj3ESeuKcHcLg MeV1qKUb8JLhvpP3Ss2kx5bzhwZ7em7IHquTN7ArtpXVxak/6oJ26ms/t4dPa8ztzfiyzONpCSLR mP4bf4g3lx2mj0rrxcNMw69YPoBc/wAAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAA EwAAAAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9Cxb vwAAABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQBwj4TG zgAAAOgAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA AgMAAAAA " o:spid="_x0000_s1103" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group>CPL: A H As <v:group coordsize="94488,94488" id="_x0000_s1099" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQBC6kD3MgIAAF4FAAAOAAAAZHJzL2Uyb0RvYy54bWykVMtu2zAQvBfoPxC6x5JtpXEE2zkkjS9F GyDpB9Ak9QAoLkHSlv33Xa4s2UnQHBIdpCU5XO3MDrm8O7Sa7ZXzDZhVMp1kCVNGgGxMtUr+vjxe LRLmAzeSazBqlRyVT+7W378tO1uoGdSgpXIMkxhfdHaV1CHYIk29qFXL/QSsMrhYgmt5wKGrUul4 h9lbnc6y7EfagZPWgVDe4+xDv5isKX9ZKhH+lKVXgelVgrUFejt6b+M7XS95UTlu60acyuCfqKLl jcGfjqkeeOBs55p3qdpGOPBQhomANoWybIQiDshmmr1hs3Gws8SlKrrKjjKhtG90+nRa8Xu/cfbZ PjlUorMVakGjyOVQujZ+sUp2IMmOo2TqEJjAyds8X2CLBa70IQkqalT93R5R//xgVzr8MH1VRmfR GP7M3X+N+3PNrSJJfYHcnxxrJPo2u51dz+fZ4jphhrfoU8KxPJ/f3MyjSWIZiB+F8oVHzb6i0siX F2Lnw0YBic33v3zoXSmHiNdDJA5mCB16+0NXWx7ivlhjDFk3tIjVQxTXWtirFyBUOLdsbCaWeUZo c4k89f6y9YgeMMPXUtYzls7cf3F4RgeTXWCEBq9QFJyKVMaA6OHkpYAGHhutSUFtiPQ0z9GhHG8X ZySdUg+6kREWaXtXbe+1Y3se7wh6Yscx7SsYnkUj+3lt4j5F10vfDvTs4IgYbUEe6UTRPNoX00VX 4yGmxKcLJ94Sl2NCna/F9T8AAAD//wMAUEsDBBQABgAIAAAAIQDeA9KM3QAAAAgBAAAPAAAAZHJz L2Rvd25yZXYueG1sTI9BT8JAEIXvJv6HzZB4k21FjZRuCQH1REwEE8Jt6A5tQ3e26S5t+fcuetDL m0xe5s370vlgatFR6yrLCuJxBII4t7riQsHX9u3+BYTzyBpry6TgQg7m2e1Niom2PX9St/GFCCHs ElRQet8kUrq8JINubBvi4B1ta9CHtS2kbrEP4aaWD1H0LA1WHD6U2NCypPy0ORsF7z32i0n82q1P x+Vlv3362K1jUupuNKxmQRYzEJ4G/3cBV4bQH7JQ7GDPrJ2oFQQa/6NX73EK4vA7ZZbK/wDZNwAA AP//AwBQSwECLQAUAAYACAAAACEAtoM4kv4AAADhAQAAEwAAAAAAAAAAAAAAAAAAAAAAW0NvbnRl bnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAAAAAAAAAAAAAAC8B AABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQBC6kD3MgIAAF4FAAAOAAAAAAAAAAAAAAAAAC4C AABkcnMvZTJvRG9jLnhtbFBLAQItABQABgAIAAAAIQDeA9KM3QAAAAgBAAAPAAAAAAAAAAAAAAAA AIwEAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAQABADzAAAAlgUAAAAA "><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443773" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQATcgUjzgAAAOgAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI/BasMw DIbvg72D0WCXsNprScnSumVsDHZdWmh3E7aaZI3lELtt9vZzobCLQPr5P/Et16PrxJmG0HrW8DxR IIiNty3XGrabj6cCRIjIFjvPpOGXAqxX93dLLK2/8Bedq1iLBOFQooYmxr6UMpiGHIaJ74lTdvCD w5jWoZZ2wEuCu05OlZpLhy2nDw329NaQOVYnp2GXbSuTZ6f+mGe0Uz/fhTnsjdaPD+P7Io3XBYhI Y/xv3BCfNjmol2k+m6kih6tYOoBc/QEAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAA EwAAAAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9Cxb vwAAABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQATcgUj zgAAAOgAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA AgMAAAAA " o:spid="_x0000_s1100" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group></td></tr><tr><td colspan="7" valign="top" width="402">State:</td><td colspan="2" valign="top" width="201"><v:group coordsize="373380,94488" id="_x0000_s1096" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQD/Bum+cQIAACQIAAAOAAAAZHJzL2Uyb0RvYy54bWzsVU2PmzAQvVfqf7C4N+SDTQCF7KHbzaVq V9rtD3CM+ZCMbdlOSP59xwMkbFJV7Va9VOUAA34e5r15ttf3x0aQAze2VjILZpNpQLhkKq9lmQXf Xh4/xAGxjsqcCiV5Fpy4De4379+tW53yuaqUyLkhkETatNVZUDmn0zC0rOINtROluYTBQpmGOng1 ZZgb2kL2RoTz6XQZtsrk2ijGrYWvD91gsMH8RcGZ+1oUljsisgBqc3g3eN/5e7hZ07Q0VFc168ug b6iiobWEn55TPVBHyd7UN6mamhllVeEmTDWhKoqaceQAbGbTKzZbo/YauZRpW+qzTCDtlU5vTsu+ HLZGP+snA0q0ugQt8M1zORam8U+okhxRstNZMn50hMHHxWqxiEFYBkPJIoEQFWUVyH4ziVWffjQt iuLYTwuHX4avCmk1WMNe2Ns/Y/9cUc1RVJsC+ydD6jwLortlMlsu47uASNqAURFGomixWia+OF8F wM9K2dSCaL8qU4IcO5Vu6NKU7a3bcoVq08Nn61DEMh8iWg0RO8ohNGDun9paU+fn+Rp9SFpoUVdH NUR+rFEH/qIQ5S4t65BdVy4IIcfIPptv/YjUgBmeGrNesGgR6PUwPjw7HHhpcNkIw4SyvCvGU0Gv nOkBbiygVI+1EKigkEh6FkXgUArbi5E5LlOrRJ17mKdtTbn7KAw5UL9J4NXb8RUMFqPMuxqE9PM4 7i9dO8CygyN8tFP5CZcUfgf3dgb66zaeA9Fr/65mv+Xf+SqOk/mlC8CzX7R9C3Gpj/o9bBPjHvw3 8b9pYtyZ4SjCBdgfm/6sG79DPD7cN98BAAD//wMAUEsDBBQABgAIAAAAIQDzOPE63wAAAAwBAAAP AAAAZHJzL2Rvd25yZXYueG1sTE9Nb8IwDL1P2n+IjLTbSMsEYqUpQuzjhCYNJk3cTGPaiiapmtCW fz/3NC72s579/F66HkwtOmp95ayCeBqBIJs7XdlCwc/h43kJwge0GmtnScGNPKyzx4cUE+16+03d PhSCRaxPUEEZQpNI6fOSDPqpa8gyd3atwcBjW0jdYs/ippazKFpIg5XlDyU2tC0pv+yvRsFnj/3m JX7vdpfz9nY8zL9+dzEp9TQZ3lZcNisQgYbwfwFjBvYPGRs7uavVXtQK5osZb3LnWCMdj+DE4HUJ MkvlfYjsDwAA//8DAFBLAQItABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAA AABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAA AAAAAAAALwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAP8G6b5xAgAAJAgAAA4AAAAAAAAA AAAAAAAALgIAAGRycy9lMm9Eb2MueG1sUEsBAi0AFAAGAAgAAAAhAPM48TrfAAAADAEAAA8AAAAA AAAAAAAAAAAAywQAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAADXBQAAAAA= "><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443769" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQDW0WJvzQAAAOcAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvhf6H5RW8hLqxNCFGVyktQq+Ngvb22H0m0ezbkF01/ffdQsHLwDDMN8xyPdpOXGnwrWMFs2kK glg703KtYLfdPBcgfEA22DkmBT/kYb16fFhiadyNv+hahVpECPsSFTQh9KWUXjdk0U9dTxyzoxss hmiHWpoBbxFuO/mSprm02HJcaLCn94b0ubpYBftkV+ksufTnLKF9evou9PGglZo8jR+LKG8LEIHG cG/8Iz6Ngtcsn8/yvMjg71f8BHL1CwAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAAT AAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/ AAAAFQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhANbRYm/N AAAA5wAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAAB AwAAAAA= " o:spid="_x0000_s1097" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443771" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQCHbIiOxgAAAOAAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Bi8Iw FITvC/6H8AQvRVNlFalGEUXwul1BvT2SZ1ttXkoTtf77zcLCXgaGYb5hluvO1uJJra8cKxiPUhDE 2pmKCwXH7/1wDsIHZIO1Y1LwJg/rVe9jiZlxL/6iZx4KESHsM1RQhtBkUnpdkkU/cg1xzK6utRii bQtpWnxFuK3lJE1n0mLFcaHEhrYl6Xv+sApOyTHX0+TR3KcJndLbZa6vZ63UoN/tFlE2CxCBuvDf +EMcjILJJ/weimdArn4AAAD//wMAUEsBAi0AFAAGAAgAAAAhANvh9svuAAAAhQEAABMAAAAAAAAA AAAAAAAAAAAAAFtDb250ZW50X1R5cGVzXS54bWxQSwECLQAUAAYACAAAACEAWvQsW78AAAAVAQAA CwAAAAAAAAAAAAAAAAAfAQAAX3JlbHMvLnJlbHNQSwECLQAUAAYACAAAACEAh2yIjsYAAADgAAAA DwAAAAAAAAAAAAAAAAAHAgAAZHJzL2Rvd25yZXYueG1sUEsFBgAAAAADAAMAtwAAAPoCAAAAAA== " o:spid="_x0000_s1098" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group>IR: A H As <v:group coordsize="94488,94488" id="_x0000_s1094" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQCgqomhKgIAAFYFAAAOAAAAZHJzL2Uyb0RvYy54bWykVM1u2zAMvg/YOwi6L05So+2MOD2say7D VqDdAyiS/APIoiApcfL2o5jYTlush9YHmaIoit/Hn9XdoTNsr31owZZ8MZtzpq0E1dq65H+fH77d chaisEoYsLrkRx343frrl1XvCr2EBozSnqETG4relbyJ0RVZFmSjOxFm4LTFwwp8JyJufZ0pL3r0 3plsOZ9fZz145TxIHQJq70+HfE3+q0rL+Keqgo7MlBxji7R6WrdpzdYrUdReuKaV5zDEB6LoRGvx 0dHVvYiC7Xz7xlXXSg8BqjiT0GVQVa3UhAHRLOav0Gw87BxhqYu+diNNSO0rnj7sVv7eb7x7co8e mehdjVzQLmE5VL5Lf4ySHYiy40iZPkQmUfk9z28xxRJPTiIRKhtk/c0d2fx851Y2PJi9CKN3WBhh wh4+h/2pEU4TpaFA7I+etarky2vOrOiwPumc5fnVzc1VKo70PNqNBIUiIFefYWfEKQq5C3GjgUgW +18hnqpRDZJoBkke7CB6rOl3q9mJmO6lGJPI+iE1rBmkdNbBXj8DWcUpVWMSMczJwthLy3POL1OO 1oPN8HfkdbKlXvuvHfbmUFwXNtJA0EgKqhKUUSB4qLwk0MJDawwxaCyBXuQ5VqbAqeKtou4MYFqV zBLs4OvtD+PZXqTZQF/KOLp9YYY9aNVJb2y6p2msnNKBtTpURJK2oI7USaTHskV3qZqxecnxedCk 6XC5J6tpHK7/AQAA//8DAFBLAwQUAAYACAAAACEA3gPSjN0AAAAIAQAADwAAAGRycy9kb3ducmV2 LnhtbEyPQU/CQBCF7yb+h82QeJNtRY2UbgkB9URMBBPCbegObUN3tukubfn3LnrQy5tMXubN+9L5 YGrRUesqywricQSCOLe64kLB1/bt/gWE88gaa8uk4EIO5tntTYqJtj1/UrfxhQgh7BJUUHrfJFK6 vCSDbmwb4uAdbWvQh7UtpG6xD+Gmlg9R9CwNVhw+lNjQsqT8tDkbBe899otJ/NqtT8flZb99+tit Y1LqbjSsZkEWMxCeBv93AVeG0B+yUOxgz6ydqBUEGv+jV+9xCuLwO2WWyv8A2TcAAAD//wMAUEsB Ai0AFAAGAAgAAAAhALaDOJL+AAAA4QEAABMAAAAAAAAAAAAAAAAAAAAAAFtDb250ZW50X1R5cGVz XS54bWxQSwECLQAUAAYACAAAACEAOP0h/9YAAACUAQAACwAAAAAAAAAAAAAAAAAvAQAAX3JlbHMv LnJlbHNQSwECLQAUAAYACAAAACEAoKqJoSoCAABWBQAADgAAAAAAAAAAAAAAAAAuAgAAZHJzL2Uy b0RvYy54bWxQSwECLQAUAAYACAAAACEA3gPSjN0AAAAIAQAADwAAAAAAAAAAAAAAAACEBAAAZHJz L2Rvd25yZXYueG1sUEsFBgAAAAAEAAQA8wAAAI4FAAAAAA== "><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_443773" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQAY8rNixQAAAOAAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Bi8Iw FITvC/6H8AQvRVMFRapRRBG82hXU2yN5ttXmpTRR67/fLCzsZWAY5htmue5sLV7U+sqxgvEoBUGs nam4UHD63g/nIHxANlg7JgUf8rBe9b6WmBn35iO98lCICGGfoYIyhCaT0uuSLPqRa4hjdnOtxRBt W0jT4jvCbS0naTqTFiuOCyU2tC1JP/KnVXBOTrmeJs/mMU3onN6vc327aKUG/W63iLJZgAjUhf/G H+JgFExm8HsongG5+gEAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAAAAAAAAAA AAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAAABUBAAAL AAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQAY8rNixQAAAOAAAAAP AAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA+QIAAAAA " o:spid="_x0000_s1095" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group></td></tr><tr><td valign="top" width="40">1 </td><td colspan="8" valign="top" width="562">Details of the flight</td></tr><tr><td colspan="5" valign="top" width="311">Group, class, type of aircraft:</td><td colspan="4" valign="top" width="292">Registration:</td></tr><tr><td colspan="2" valign="top" width="165">Aerodrome or site: </td><td colspan="3" valign="top" width="146">Take-off time: </td><td colspan="3" valign="top" width="146">Landing time: </td><td valign="top" width="146">Flight time: </td></tr><tr><td colspan="2" valign="top" width="165"></td><td colspan="3" valign="top" width="146"></td><td colspan="3" valign="top" width="146"></td><td valign="top" width="146"></td></tr><tr><td colspan="2" valign="top" width="165"></td><td colspan="3" valign="top" width="146"></td><td colspan="3" valign="top" width="146"></td><td valign="top" width="146"></td></tr><tr><td colspan="2" valign="top" width="165"></td><td colspan="3" valign="top" width="146"></td><td colspan="3" valign="top" width="146"></td><td valign="top" width="146"></td></tr><tr><td colspan="2" valign="top" width="165"></td><td colspan="3" valign="top" width="146"></td><td colspan="3" valign="top" width="146"></td><td valign="top" width="146"></td></tr><tr><td colspan="2" valign="top" width="165"></td><td colspan="3" valign="top" width="146"></td><td colspan="3" valign="top" width="146"></td><td valign="top" width="146">Total flight time: </td></tr><tr><td valign="top" width="40">2 </td><td colspan="8" valign="top" width="562">Result of the test </td></tr><tr><td colspan="9" valign="top" width="603">Skill test details: </td></tr><tr><td colspan="3" valign="top" width="173">Pass <v:group coordsize="94488,94488" id="Group_x0020_4367171" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQB5GtT6KQIAAFYFAAAOAAAAZHJzL2Uyb0RvYy54bWykVM1u2zAMvg/YOwi+L04Cd8iMOD2say7D VqDtAyiS/APIoiApdvL2o+jYTlush9YHmaIoit/Hn+3tqdWsU843YIpktVgmTBkBsjFVkTw/3X/b JMwHbiTXYFSRnJVPbndfv2x7m6s11KClcgydGJ/3tkjqEGyepl7UquV+AVYZPCzBtTzg1lWpdLxH 761O18vl97QHJ60DobxH7d1wmOzIf1kqEf6WpVeB6SLB2AKtjtZDXNPdlueV47ZuxCUM/oEoWt4Y fHRydccDZ0fXvHHVNsKBhzIsBLQplGUjFGFANKvlKzR7B0dLWKq8r+xEE1L7iqcPuxV/ur2zj/bB IRO9rZAL2kUsp9K18Y9RshNRdp4oU6fABCp/ZNkGUyzwZBCJUFEj62/uiPrXO7fS8cH0RRi9xcLw M3b/OeyPNbeKKPU5Yn9wrJFFskYIhrdYn3TOsiy72dzE4ojPo91EkM89cvUZdiacPBdHH/YKiGTe /fZhqEY5SrweJXEyo+iwpt+tZstDvBdjjCLrx9SwepTiWQudegKyCnOqpiRimLOFNteWl5xfpxyt R5vxb8nrbEu99l877M2xuK5shAavkBRURSiTQPBQeU2ggftGa2JQGwK9yjKsTI5TxRlJ3elBNzKa RdjeVYef2rGOx9lAX8w4un1hhj1o5KDXJt5TNFaGdGCtjhURpQPIM3US6bFs0V2sZmxecnwZNHE6 XO/Jah6Hu38AAAD//wMAUEsDBBQABgAIAAAAIQDeA9KM3QAAAAgBAAAPAAAAZHJzL2Rvd25yZXYu eG1sTI9BT8JAEIXvJv6HzZB4k21FjZRuCQH1REwEE8Jt6A5tQ3e26S5t+fcuetDLm0xe5s370vlg atFR6yrLCuJxBII4t7riQsHX9u3+BYTzyBpry6TgQg7m2e1Niom2PX9St/GFCCHsElRQet8kUrq8 JINubBvi4B1ta9CHtS2kbrEP4aaWD1H0LA1WHD6U2NCypPy0ORsF7z32i0n82q1Px+Vlv3362K1j UupuNKxmQRYzEJ4G/3cBV4bQH7JQ7GDPrJ2oFQQa/6NX73EK4vA7ZZbK/wDZNwAAAP//AwBQSwEC LQAUAAYACAAAACEAtoM4kv4AAADhAQAAEwAAAAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNd LnhtbFBLAQItABQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAAAAAAAAAAAAAAC8BAABfcmVscy8u cmVsc1BLAQItABQABgAIAAAAIQB5GtT6KQIAAFYFAAAOAAAAAAAAAAAAAAAAAC4CAABkcnMvZTJv RG9jLnhtbFBLAQItABQABgAIAAAAIQDeA9KM3QAAAAgBAAAPAAAAAAAAAAAAAAAAAIMEAABkcnMv ZG93bnJldi54bWxQSwUGAAAAAAQABADzAAAAjQUAAAAA " o:spid="_x0000_s1092"><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_444585" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQAGIYKLxwAAAOAAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI/BasJA EIbvQt9hmUIvoW4qKBJdpbQUejUK2tuwOyap2dmQXTW+vXMQvAz8DP838y3Xg2/VhfrYBDbwMc5B EdvgGq4M7LY/73NQMSE7bAOTgRtFWK9eRkssXLjyhi5lqpRAOBZooE6pK7SOtiaPcRw6YtkdQ+8x Sewr7Xq8Cty3epLnM+2xYblQY0dfNdlTefYG9tmutNPs3J2mGe3z/7+5PR6sMW+vw/dCxucCVKIh PRsPxK8zMJGPRUhkQK/uAAAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAAAAA AAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAAFQEA AAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAAYhgovHAAAA4AAA AA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD7AgAAAAA= " o:spid="_x0000_s1093" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group></td><td colspan="3" valign="top" width="146">Fail <v:group coordsize="94488,94488" id="_x0000_s1090" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQD2rM5UKAIAAFoFAAAOAAAAZHJzL2Uyb0RvYy54bWykVE1v2zAMvQ/YfxB0b5wU7pAZcXpY21yG rUDbH6BI8gcgi4KkxMm/H8XEjttiPbQ+2BT1RPM9UlzdHjrD9tqHFmzJF7M5Z9pKUK2tS/7y/HC1 5CxEYZUwYHXJjzrw2/X3b6veFfoaGjBKe4ZBbCh6V/ImRldkWZCN7kSYgdMWNyvwnYi49HWmvOgx emey6/n8R9aDV86D1CGg9+60ydcUv6q0jH+rKujITMkxt0hvT+9temfrlShqL1zTynMa4hNZdKK1 +NMx1J2Igu18+y5U10oPAao4k9BlUFWt1MQB2Szmb9hsPOwccamLvnajTCjtG50+HVb+2W+8e3KP HpXoXY1a0CpxOVS+S1/Mkh1IsuMomT5EJtH5M8+XWGKJOyeTBJUNqv7ujGzuPziVDT/MXqXRO2yM cOEevsb9qRFOk6ShQO6PnrWq5Hme3yxvOLOiwx4lDDv7SBbCjiKFIqBeX1Fo5CoKuQtxo4GEFvvf IZ46Ug2WaAZLHuxgeuzrDzvaiZjOpRyTyfqhPKwZrLTXwV4/A6HipVxjITHNC8LYKfJc92nZET1g hq+jqBcs3bf/4vB+Dg02wUgDQaMo6EpURoPooXMqoIWH1hhS0Fgivchz7E6Bk8VbRTc0gGlVgiXa wdfbX8azvUjzgZ40EjDsKxjeQ6tOfmPTOU2j5VQO7NehI5K1BXWk20R+bF0MlzoaLzAFPg+bNCGm a0JdRuL6HwAAAP//AwBQSwMEFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAABkcnMvZG93bnJldi54 bWxMj0FPwkAQhe8m/ofNkHiTbUWNlG4JAfVETAQTwm3oDm1Dd7bpLm359y560MubTF7mzfvS+WBq 0VHrKssK4nEEgji3uuJCwdf27f4FhPPIGmvLpOBCDubZ7U2KibY9f1K38YUIIewSVFB63yRSurwk g25sG+LgHW1r0Ie1LaRusQ/hppYPUfQsDVYcPpTY0LKk/LQ5GwXvPfaLSfzarU/H5WW/ffrYrWNS 6m40rGZBFjMQngb/dwFXhtAfslDsYM+snagVBBr/o1fvcQri8Dtllsr/ANk3AAAA//8DAFBLAQIt ABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10u eG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAAAAAAAAAALwEAAF9yZWxzLy5y ZWxzUEsBAi0AFAAGAAgAAAAhAPaszlQoAgAAWgUAAA4AAAAAAAAAAAAAAAAALgIAAGRycy9lMm9E b2MueG1sUEsBAi0AFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAAAAAAAAAAAAAAAAggQAAGRycy9k b3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAACMBQAAAAA= "><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_444585" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQAPlDSNygAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvhf6H5RV6CXWjJBKiq5SK0KupYHt77D6T1OzbkF01/fddQfAyMAzzDbNcj7YTFxp861jBdJKC INbOtFwr2H9t3woQPiAb7ByTgj/ysF49Py2xNO7KO7pUoRYRwr5EBU0IfSml1w1Z9BPXE8fs6AaL IdqhlmbAa4TbTs7SdC4tthwXGuzpoyF9qs5WwSHZVzpPzv0pT+iQ/v4U+vitlXp9GTeLKO8LEIHG 8GjcEZ9GQZZleZHD7VQ8BHL1DwAA//8DAFBLAQItABQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAA AAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10ueG1sUEsBAi0AFAAGAAgAAAAhAFr0LFu/AAAA FQEAAAsAAAAAAAAAAAAAAAAAHwEAAF9yZWxzLy5yZWxzUEsBAi0AFAAGAAgAAAAhAA+UNI3KAAAA 5AAAAA8AAAAAAAAAAAAAAAAABwIAAGRycy9kb3ducmV2LnhtbFBLBQYAAAAAAwADALcAAAD+AgAA AAA= " o:spid="_x0000_s1091" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group></td><td colspan="3" valign="top" width="284">Partial pass <v:group coordsize="94488,94488" id="Group_x0020_4367193" o:gfxdata="UEsDBBQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJU67QAgl6YK0S0CoHGBkTxKLZGx5TGhvj5O2G0SRWNoz/78nu9wcxkFMGNg6quQqL6RA 0s5Y6ir5vt9lD1JwBDIwOMJKHpHlpr69KfdHjyxSmriSfYz+USnWPY7AufNIadK6MEJMx9ApD/oD OlTrorhX2lFEilmcO2RdNtjC5xDF9pCuTyYBB5bi6bQ4syoJ3g9WQ0ymaiLzg5KdCXlKLjvcW893 SUOqXwnz5DrgnHtJTxOsQfEKIT7DmDSUCaxw7Rqn8787ZsmRM9e2VmPeBN4uqYvTtW7jvijg9N/y JsXecLq0q+WD6m8AAAD//wMAUEsDBBQABgAIAAAAIQA4/SH/1gAAAJQBAAALAAAAX3JlbHMvLnJl bHOkkMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr2M4PBMnrbUb/Q94l/f/hMi1qR JVI2sOt6UJgd+ZiDgffL8ekFlFSbvV0oo4EbChzGx4f9GRdb25HMsYhqlCwG5lrLq9biZkxWOiqY 22YiTra2kYMu1l1tQD30/bPm3wwYN0x18gb45AdQl1tp5j/sFB2T0FQ7R0nTNEV3j6o9feQzro1i OWA14Fm+Q8a1a8+Bvu/d/dMb2JY5uiPbhG/ktn4cqGU/er3pcvwCAAD//wMAUEsDBBQABgAIAAAA IQAspzACKAIAAFoFAAAOAAAAZHJzL2Uyb0RvYy54bWykVE1v2zAMvQ/YfxB0b5wU3pYZcXpo11yG rUDbH6BI8gcgi4KkxMm/H0XHTtpiPbQ+2BT1RPM9UlzdHDrD9tqHFmzJF7M5Z9pKUK2tS/78dH+1 5CxEYZUwYHXJjzrwm/XXL6veFfoaGjBKe4ZBbCh6V/ImRldkWZCN7kSYgdMWNyvwnYi49HWmvOgx emey6/n8e9aDV86D1CGg927Y5GuKX1Vaxr9VFXRkpuSYW6S3p/c2vbP1ShS1F65p5SkN8YEsOtFa /OkU6k5EwXa+fROqa6WHAFWcSegyqKpWauKAbBbzV2w2HnaOuNRFX7tJJpT2lU4fDiv/7DfePboH j0r0rkYtaJW4HCrfpS9myQ4k2XGSTB8ik+j8medLLLHEncEkQWWDqr85I5tf75zKxh9mL9LoHTZG OHMPn+P+2AinSdJQIPcHz1pV8jzPvy1/cGZFhz1KGHbykSyEnUQKRUC9PqPQxFUUchfiRgMJLfa/ Qxw6Uo2WaEZLHuxoeuzrdzvaiZjOpRyTyfqxPKwZrbTXwV4/AaHiuVxTITHNM8LYS+Sp7pdlR/SI Gb+Oop6xdN/+i8P7OTbYBUYaCBpFQVeiMhlED52XAlq4b40hBY0l0os8x+4UOFm8VXRDA5hWJVii HXy9vTWe7UWaD/SkkYBhX8DwHlo1+I1N5zSNlqEc2K9jRyRrC+pIt4n82LoYLnU0XmAKfBo2aUJc rgl1HonrfwAAAP//AwBQSwMEFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAABkcnMvZG93bnJldi54 bWxMj0FPwkAQhe8m/ofNkHiTbUWNlG4JAfVETAQTwm3oDm1Dd7bpLm359y560MubTF7mzfvS+WBq 0VHrKssK4nEEgji3uuJCwdf27f4FhPPIGmvLpOBCDubZ7U2KibY9f1K38YUIIewSVFB63yRSurwk g25sG+LgHW1r0Ie1LaRusQ/hppYPUfQsDVYcPpTY0LKk/LQ5GwXvPfaLSfzarU/H5WW/ffrYrWNS 6m40rGZBFjMQngb/dwFXhtAfslDsYM+snagVBBr/o1fvcQri8Dtllsr/ANk3AAAA//8DAFBLAQIt ABQABgAIAAAAIQC2gziS/gAAAOEBAAATAAAAAAAAAAAAAAAAAAAAAABbQ29udGVudF9UeXBlc10u eG1sUEsBAi0AFAAGAAgAAAAhADj9If/WAAAAlAEAAAsAAAAAAAAAAAAAAAAALwEAAF9yZWxzLy5y ZWxzUEsBAi0AFAAGAAgAAAAhACynMAIoAgAAWgUAAA4AAAAAAAAAAAAAAAAALgIAAGRycy9lMm9E b2MueG1sUEsBAi0AFAAGAAgAAAAhAN4D0ozdAAAACAEAAA8AAAAAAAAAAAAAAAAAggQAAGRycy9k b3ducmV2LnhtbFBLBQYAAAAABAAEAPMAAACMBQAAAAA= " o:spid="_x0000_s1088"><v:shape coordsize="94488,94488" filled="f" id="Shape_x0020_444587" o:gfxdata="UEsDBBQABgAIAAAAIQDb4fbL7gAAAIUBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbHyQz07DMAyH 70i8Q+QralM4IITa7kDhCAiNB7ASt43WOlEcyvb2pNu4IODoPz9/n1xv9vOkForiPDdwXVagiI23 jocG3rdPxR0oScgWJ8/UwIEENu3lRb09BBKV0ywNjCmFe63FjDSjlD4Q50nv44wpl3HQAc0OB9I3 VXWrjedEnIq03oC27qjHjympx31un0wiTQLq4bS4shrAECZnMGVTvbD9QSnOhDInjzsyuiBXWQP0 r4R18jfgnHvJr4nOknrFmJ5xzhraRtHWf3Kkpfz/yGo5S+H73hkquyhdjr3R8m2lj09svwAAAP// AwBQSwMEFAAGAAgAAAAhAFr0LFu/AAAAFQEAAAsAAABfcmVscy8ucmVsc2zPwWrDMAwG4Ptg72B0 X5TuUMaI01uh19I+gLGVxCy2jGSy9e1nemrHjpL4P0nD4SetZiPRyNnCruvBUPYcYp4tXC/Htw8w Wl0ObuVMFm6kcBhfX4Yzra62kC6xqGlKVgtLreUTUf1CyWnHhXKbTCzJ1VbKjMX5LzcTvvf9HuXR gPHJNKdgQU5hB+ZyK23zHztFL6w81c5zQp6m6P9TMfB3PtPWFCczVQtB9N4U2rp2HOA44NMz4y8A AAD//wMAUEsDBBQABgAIAAAAIQCQCg9hywAAAOQAAAAPAAAAZHJzL2Rvd25yZXYueG1sRI9Ba8JA FITvhf6H5RW8hLqxJG2IrlIsQq+mgu3tsftMUrNvQ3bV9N+7gtDLwDDMN8xiNdpOnGnwrWMFs2kK glg703KtYPe1eS5A+IBssHNMCv7Iw2r5+LDA0rgLb+lchVpECPsSFTQh9KWUXjdk0U9dTxyzgxss hmiHWpoBLxFuO/mSpq/SYstxocGe1g3pY3WyCvbJrtJ5cuqPeUL79Pen0IdvrdTkafyYR3mfgwg0 hv/GHfFpFGRZlhdvcDsVD4FcXgEAAP//AwBQSwECLQAUAAYACAAAACEA2+H2y+4AAACFAQAAEwAA AAAAAAAAAAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQBa9CxbvwAA ABUBAAALAAAAAAAAAAAAAAAAAB8BAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQCQCg9hywAA AOQAAAAPAAAAAAAAAAAAAAAAAAcCAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAMAAwC3AAAA/wIA AAAA " o:spid="_x0000_s1089" path="m,94488r94488,l94488,,,,,94488xe" strokeweight=".72pt"></v:shape></v:group></td></tr><tr><td valign="top" width="40">3 </td><td colspan="8" valign="top" width="562">Remarks </td></tr><tr><td colspan="9" valign="top" width="603"></td></tr><tr><td colspan="9" valign="top" width="603"></td></tr><tr><td colspan="9" valign="top" width="603"></td></tr><tr><td colspan="9" valign="top" width="603"></td></tr><tr><td colspan="9" valign="top" width="603"></td></tr><tr><td colspan="9" valign="top" width="603"></td></tr><tr><td colspan="9" valign="top" width="603">Location and date: </td></tr><tr><td colspan="4" valign="top" width="297">Examiner’s certificate number *: </td><td colspan="5" valign="top" width="306">Type and number of licence: </td></tr><tr><td colspan="4" valign="top" width="297">Signature of examiner: </td><td colspan="5" valign="top" width="306">Name(s) in capital letters: </td></tr><tr height="0"></tr></table>

\* if applicable

##### AMC1 to Appendix 7 IR skill test

*ED Decision 2025/002/R*

**LAPL,
PPL, CPL, IR SKILL TEST AND PROFICIENCY CHECK APPLICATION AND REPORT
FORM**

<table cellpadding="7" cellspacing="0">
<col/>
<col/>
<col/>
<col/>
<col/>
<col/>
<col/>
<col/>
<col/>
<tr>
<td colspan="9" valign="top">
APPLICATION
			AND REPORT FORM 

LAPL,
			PPL, CPL, IR SKILL TEST AND PROFICIENCY CHECK 

</td>
</tr>
<tr valign="top">
<td colspan="7">
Applicant’s
			last name(s):
</td>
<td colspan="2">

</td>
</tr>
<tr valign="top">
<td colspan="7">
Applicant’s
			first name(s):
</td>
<td colspan="2">
L<img align="left" alt="Shape2" hspace="1" name="Shape2" src="source-marked.part-0013_html_925dff98.gif" vspace="1"/>
APL:
			 A 	 H 	
</td>
</tr>
<tr valign="top">
<td colspan="7">
Signature
			of applicant:
</td>
<td colspan="2">
 

</td>
</tr>
<tr valign="top">
<td colspan="7">
Type
			of licence*:
</td>
<td colspan="2">
P<img align="left" alt="Shape3" name="Shape3" src="source-marked.part-0013_html_925dff98.gif"/>
PL:
			A 	 H 	 As 
			<img align="bottom" alt="Shape4" name="Shape4" src="source-marked.part-0013_html_756a4c65.gif"/>

</td>
</tr>
<tr valign="top">
<td colspan="7">
Licence
			number*:
</td>
<td colspan="2">
C<img align="left" alt="Shape5" name="Shape5" src="source-marked.part-0013_html_925dff98.gif"/>
PL:
			A 	 H 	 As 
			<img align="bottom" alt="Shape6" name="Shape6" src="source-marked.part-0013_html_756a4c65.gif"/>

</td>
</tr>
<tr valign="top">
<td colspan="7">
State:
</td>
<td colspan="2">
I<img align="left" alt="Shape7" name="Shape7" src="source-marked.part-0013_html_925dff98.gif"/>
R:
			 A 	 H 	 As 
			<img align="bottom" alt="Shape8" name="Shape8" src="source-marked.part-0013_html_756a4c65.gif"/>

</td>
</tr>
<tr valign="top">
<td>
1
			

</td>
<td colspan="8">
Details
			of the flight
</td>
</tr>
<tr valign="top">
<td colspan="5">
Class,
			type of aircraft:
</td>
<td colspan="4">
Registration:
</td>
</tr>
<tr valign="top">
<td colspan="2">
Aerodrome
			or site: 

</td>
<td colspan="3">
Take-off
			time: 

</td>
<td colspan="3">
Landing
			time: 

</td>
<td>
Flight
			time: 

</td>
</tr>
<tr valign="top">
<td colspan="2">

</td>
<td colspan="3">

</td>
<td colspan="3">

</td>
<td>

</td>
</tr>
<tr valign="top">
<td colspan="2">

</td>
<td colspan="3">

</td>
<td colspan="3">

</td>
<td>

</td>
</tr>
<tr valign="top">
<td colspan="2">

</td>
<td colspan="3">

</td>
<td colspan="3">

</td>
<td>

</td>
</tr>
<tr valign="top">
<td colspan="2">

</td>
<td colspan="3">

</td>
<td colspan="3">

</td>
<td>

</td>
</tr>
<tr valign="top">
<td colspan="2">

</td>
<td colspan="3">

</td>
<td colspan="3">

</td>
<td>
Total
			flight time: 

</td>
</tr>
<tr valign="top">
<td>
2
			

</td>
<td colspan="8">
Result
			of the test 

</td>
</tr>
<tr>
<td colspan="9" valign="top">
Skill
			test details: 

</td>
</tr>
<tr valign="top">
<td colspan="3">
Pass	<img align="bottom" alt="Shape9" name="Shape9" src="source-marked.part-0013_html_756a4c65.gif"/>

</td>
<td colspan="3">
Fail	<img align="bottom" alt="Shape10" name="Shape10" src="source-marked.part-0013_html_756a4c65.gif"/>

</td>
<td colspan="3">
Partial
			pass 	<img align="bottom" alt="Shape11" name="Shape11" src="source-marked.part-0013_html_756a4c65.gif"/>

</td>
</tr>
<tr valign="top">
<td>
3
			

</td>
<td colspan="8">
Remarks
			 

</td>
</tr>
<tr>
<td colspan="9" valign="top">
 

</td>
</tr>
<tr>
<td colspan="9" valign="top">

</td>
</tr>
<tr>
<td colspan="9" valign="top">

</td>
</tr>
<tr>
<td colspan="9" valign="top">

</td>
</tr>
<tr>
<td colspan="9" valign="top">

</td>
</tr>
<tr>
<td colspan="9" valign="top">

</td>
</tr>
<tr>
<td colspan="9" valign="top">
Location
			and date: 

</td>
</tr>
<tr valign="top">
<td colspan="4">
Examiner’s
			certificate number *: 

</td>
<td colspan="5">
Type
			and number of licence: 

</td>
</tr>
<tr valign="top">
<td colspan="4">
Signature
			of examiner: 

</td>
<td colspan="5">
Name(s)
			in capital letters: 

</td>
</tr>
</table>

*\* if applicable*

Compare / EASA/ Incorporated Amendments/ Compare & Highlight Differences

AMC1 to Appendix 7 IR skill test

View