0
Form Approved
MAJOR REPAIR AND ALTERATION
OMB No. 2120-0020
US Deponment
(Airframe, Powerplant, Propeller, or Appliance)
For FAA Use Only
ot Tronsportot,on
Office Identification
Federal Aviation
~A .J"'~
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Administration
INSTRUCTIONS: Print or type all entries. See FAR 43.9, FAR 43 Appendix B, and AC 43.9-1 ( or subsequent revision thereof) for instructions
and disposition of this form. This report is required by law (49 U.S.C. 1421 ). Failure to report can result in a civil penalty not to exceed $1,000
for each such violation (Section 901 Federal Aviation Act of 1958).
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Model
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1. Aircraft
Serial No.
3
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Nationality and Registration Mark
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2..\o'2. 1?
Name (As shown on registration certificate}
Address (As shown on registration certificate)
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2. Owner
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3. For FAA Use Only
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4. Unit Identification
5. Type
Unit
Make Model Serial No. Repair
Alteration
AIRFRAME
,.,.,.,.,.,.,.,.,,,,.,,.,,,,. ,, ( As described in Item 1 above) ,,,.,,,.,,,,,, .,,,,,,,
POWER PLANT
PROPELLER
Type
APPLIANCE
Servo Actuator
212-076-005-105 HR 8095
I
Manufacturer
H R Textron
6. Conformity Statement
A. Agency's Name and Address
B. Kind of Agency
C. Certificate No.
Phillip
Smith
x
U S. Certificated Mechanic
A&P 2327903
18
Wey hill Gardens,
Weyhill
Foreign Certificated Mechanic
Andover,
Hampshire,
SPll
OQT
Certificated Repair Station
U.K.
Manufacturer
D. I certify that the repair and/or alteration made to the unit(s) identified in item 4 above and described on the reverse or attachments hereto
have been made in accordance with the requirements of Part 43 of the U.S. Federal Aviation Regulations and that the information
furnished herein is true and correct to the best of my knowledge.
Date
Slgnaturn of Authol'7..Y<
19
April 1996
7. Approval for Return To Service
Pursuant to the authority given persons specified below, the unit identified in item 4 was inspected in the manner prescribed by the
Administrator of the Federal Aviation Administration and is
NJ APPROVED O REJECTED
FAA Flt. Standards
Manufacturer
x
Inspection Authorization
Other (Specify)
Inspector
BY
FAA Designee Repair Station
Person Approved by Transport
Canada Airworthiness Group
Date of Approval or Rejection Certificate or
Signaturn ot ?.''"' J({di,idual
19
April 1996
Designation No.
,v~~
1'-\&P 2327903 IA
FAA Form 337 P2·88)
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