Form No.:AIESL/FTM/1.

1/B04 Issue-2, Rev-0, MAY2017

For Component Transfer

2. AUTHORISED RELEASE CERTIFICATE 3.Form Tracking Number-

1. DGCA, India BM-NAG-B- - 19
(CA FORM 1)
4. Approved Organisation Name And Address :– 5.Work order/Contract/Invoice

Air India Engineering Services Limited (AIESL), NAG/VT- ALU /BM/

113, Gurudwara Rakabganj Road, New Delhi.

6.Item 7.Description 8.Part No. 9.Qty 10.Serial/Batch No. 11.Status/Work

AFDC 822-0006-105 01 Inspected

12. Remarks-
This is to certify that the component has been removed from serviceable Aircraft (ARC valid) / Engine (VT- ALU / Engine Sr. No- ) to install
on Aircraft / Engine (VT- ALS / Engine Sr. No- ) and meets the following requirements:
a) The last flight of the aircraft with the component fitted reveals no faults on that component/ related system and aircraft is not involved in accidents,
incidents, heavy landing or lightning strikes that could affect the serviceability of the above component.
b) The aircraft component inspected for condition, damage, corrosion or leakage.
c) The maintenance task applicable to the component, if any, as per the scheduled maintenance check of the donor aircraft is performed.

13.a.Certifies that the items Identified above were manufactured in
conformity to
□ approved design data and are in condition for safe operation
□ non approved design data as specified in block 12
14.a. CAR.145.A.50 Release to service
Other regulations specified in block 12
Certifies that unless otherwise specified in block 12 the work identified in block 11
and described in block 12 was accomplished in accordance with CAR145 and in
respect to that work the items are considered ready for release to service.

13.b Authorised Signature 13.c Approval/Authorisation 14. b. Authorised Signature and No. 14.c. Certificate/ Approval Ref
Number No.: F-APP/AIESL/2820

13.d Name 13.e Date (dd/mmm/yyyy) 14d.Name 14.e.Date(dd/mmm/yyyy)

B T PARAMESHWARA 16/APR/2019
Note: This certificate does not automatically constitute authority to install. Where the user/installer performs work in accordance with regulations of an airworthiness authority different than
the airworthiness authority specified in block 1, it is essential that user/installer ensures that his/her airworthiness authority accepts items from the airworthiness authority specified in block 1.
Statements in blocks 13a and 14a do not constitute installation certification. In all cases aircraft maintenance records must contain an installation certification issued in accordance with the
national regulations by the user/installer before the aircraft may be flown.