US
D.pubnm
MAJOR REPAIR AND ALTERATION
or
Tnnpor(rlion
(Airframe, Powerplant, Propeller, or Appliance)
F-A*
.
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AdnH.b.llon
I
INSTRUCTIONS: Print
or
lype
a1 entries.
See
FAR 43.9, FAR 43
Appendix
0,
and AC 43.91
(or
subsequent mvision
themof)
for
instructions
and
disposition of this
form.
f
his nport is
raquksd
by
Law
(40 U.S.C. 1421). Failun
to
nport
can
nwk
in
civil
pnelty
not
to
exceed
$1,000
for each such violetion (Sadion 901 F&ml Aviation
Act
of 1958).
1
2.
-r
1
Luxury Air Management, Inc
1.
Airclaft
I
30 Old Rudnick Lane
Dover, DE 19901
4. Unit Identification
&%!?
MsM
Piper
-I
No.
28R-7635256
Namo
(As
shown
on
regrjtratbn
wtthte)
I
Unit
I
MO(I(H
PA-28R-200
Nathnal'i and Registration
Mark
N323MG
Addmss
(As
shorn
on
-stration
~~)t?iticate)
Make
I
Model
Serial No.
I
Repir
I
Alterabon
-
(As
desctibed
in Item
1
above)
I
IX
POWERPLANT
I
I
PROPELLER
APPLIANCE
Form
Approved
OM0
No.
21204020
For
FAA
U..
Only
offlca
Identilicelion
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-
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D
I
cew
that
the
repair
and/or
afteration
made
to
the
unit@)
identifRd
in
item
4
above
and
desaibed
on
Vie
reverse
or
attachments
heceto
have
been
made
in accordance
with
the
requirements
of
Part
43
of
the
U.S.
Federal
Avialion Regulations
and
that
the
informalion
furnished herein is ttue
and
axred
to
the
best
of
my
knowledge.
I
I
I
I
I
6.
Conformity Statement
Date
10-19-2000
I
Pursuant
b
the
aulhonty
given
persons specified
below,
the
unil identified in item
4
was
in ~n
Vie
manner
pmsuibed
by
the
Administrator of
the
Federal
Aviation Administretion
and
is
APPROVED
y'
REJECTED
C.
Cetiicate
No.
--
A1291728591
A. Agency's Name and
Address
Chris Moyers
Aero Aviation Training Center, Inc.
4510 Airport Rd., Hangar 1
Cincinnati, Ohio 45226
B.
Kind of
Agency
X
otIw
--
U.S.
Cettificat.d
Wchank
Foreign
Cetiited
Mechanic
Cetiii
Repair
Station
Manufacturer
~~A~
Canada
~~
w
Ainvorthiness
bY
Tmna~M
Grap
BY
Dateof
Approval orRepcfion
4r
940
0
FAA
Rt Standards
Inspector
FAA
Designee
Uanufechrrer
Repair Stabon
FAA
Fonn
337
(12-98)
cdlkate
or
DeJiOnation
No.
/9Y3dk?
v
Signature
of Authofized
Individual
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