Advisory Circular (AC)

Appendix 2

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

Delegation No.

Classification of Designee Name of Employer
Model No.

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


List of Approved Reports and Data



Requirements and Status



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



Signature of Design Approval Representative

Form AE-100 (5-67)

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