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40. QUALIFICATION IN ARMS WEAPON | COURSE | QUALIFIED | SCORE | DATE 41. AWARDS, DECORATIONS AND CITATIONS TYPE | AUTHORITY AND DATE | PRESENTED (Yes or No) 42. REMARKS PAGE 3 43. FLYING STATUS AUTHORITY | DATE | RESTRICTIONS 44. RATINGS, SPECIALTIES, AND DESIGNATIONS RATING, SPECIALTY OR DESIGNATION | EFFECTIVE DATE | AUTHORITY 45. AIRPLANE QUALIFICATIONS (Military) NO. OF ENGINES | TYPE OF PLANE CONVENTIONAL 1 | - 2 | - OVER 2 | - "JET" 1 | - 2 | - OVER 2 | - OTHER | - 46. FLYING HOURS HOURS | MONTH AND YEAR 250 | 500 | 750 | 1000 | 1500 | 2000 | 3000 | 5000 | 47. CIVILIAN FLYING EXPERIENCE (Nature, type equipment, no. hrs., last date flown, licenses) 48. COMBAT DATA (AAF only) 49. INTERNSHIP HOSPITAL (Location) | TYPE | TOTAL MONTHS | YEAR COMPLETED 50. PRIVATE PRACTICE LOCATION AND TYPE | % OF TIME | FROM | TO 51. RESIDENCIES AND FELLOWSHIPS HOSPITAL (Location) | SERVICE | TOTAL MONTHS | YEAR COMPLETED 52. POST GRADUATE INSTRUCTION INSTITUTION | COURSE | TOTAL MONTHS | YEAR COMPLETED 53. CERTIFIED BY AMERICAN BOARD OF | YEAR SUB SPECIALTY | YEAR LICENSE (Type) | STATE OR TERRITORY AND YEAR 54. HOSPITAL AND TEACHING APPOINTMENTS INSTITUTION | TYPE | HOURS WEEKLY | DATES (From - to) 55. BOOKS AND TECHNICAL PAPERS PUBLISHED | YEAR 56. PROFESSIONAL AND EDUCATIONAL SOCIETIES (with degree of membership) 57. COLOR HAIR 58. COLOR EYES 59. PHOTO 60. COMPLEXION 61. BLOOD TYPE 63. AUTHENTICATING SIGNATURE. TYPED NAME, GRADE AND ARM OR SERVICE OF OFFICER AND DATE PAGE 4 c9–16–61698–1 U. S. GOVERNMENT PRINTING OFFICE
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