Airworthiness Manual Chapter 561 - Approved Manufacturers

Canadian Aviation Regulations (CARs) 2017-2

Content last revised: 2008/12/30

APPENDICES A, B

Appendix B
Sample Statement of Conformity

Refer to subsection 561.10(6) of this standard

Instruction: Print or type all entries

1. Aircraft

Manufacturer: __________________________

Model____________ Serial No.___________ Registration Mark___________

Type Certificate No. ___________________________________

2. Engine(s)

Make

1._____________
2. ____________
3. ____________
4. ____________

Model

1._____________
2. ____________
3. ____________
4. ____________

Serial No.

1._____________
2. ____________
3. ____________
4. ____________

Type Certificate No.

1._____________
2. ____________
3. ____________
4. ____________

3. Propeller(s)

Make

1._____________
2. ____________
3. ____________
4. ____________

Model

1._____________
2. ____________
3. ____________
4. ____________

Serial No.

1._____________
2. ____________
3. ____________
4. ____________

Type Certificate No.

1._____________
2. ____________
3. ____________
4. ____________

4. Approved Modifications Embodied Subsequent to Type Certification Drawing & Issue No.

________________________________________________________

Description __________________________________________ [ ] or

as per attached list ________________________________

5. Certification

I hereby certify that the aircraft described above, produced under Manufacturing Certificate Number _________, has been manufactured in conformity to approved design data, is in a condition for safe operation and was satisfactorily flight tested on ______________.

Signed _____________________

Date _____________

On Behalf of ________________________ (Company Name)

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