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ASSESSMENT
Have you ignited yourself on a flight within the last twelve months:
□ Yes □ No
Have you attempted to ignite yourself on a flight in within the last twenty-four months:
□ Yes □ No
Have you recently received instructions on how to blow up airplanes from an avowed
terrorist?
□ Yes □ No
Is your intent of this flight to blow yourself up with as many people as possible:
□ Yes □ No
If you answered yes to any of the questions listed above, you may not board this flight.
______________________________________________ ___________________
Sign your name here Date