Advisory Circular (AC)

Department of Transport
Statement of Compliance of Aircraft or Aircraft
Components with the Airworthiness Requirements

Delegation No.

Model Type (Airplane, Radio, Helicopter, etc.)

List of Approved Reports and Data

Number

Title

Requirements and Status

CERTIFICATION

Under the authority vested in me by the Department of Transport, I hereby certify that the data listed above and on attached sheets numbered __________ have been examined in accordance with established procedures and found to comply, to the best of my knowledge and belief with the pertinent requirements.

Recommend Approval of these data

I therefore

Approve

___________________________________________

Signature of Design Approval Representative