Signed
(Signature of authorised representative)

(Facility Name)  (AMO Certificate Number)

(Address)

14 CFR: 43, Appendix B
(c) The following sample form may be used to record major modifications and repairs.
MAJOR REPAIR AND MODIFICATION
(Airframe, Powerplant, Propeller, or Appliance) [State]
For CAA Use Only
Office Identification
INSTRUCTIONS: Print or type all entries. See Model Regulation Part 5, 5.7.1.1(b) and IS: 5.7.1.1 for instructions and disposition of this form.
1.  Aircraft Make
Model
Serial Number
Nationality and Registration Mark
2.  Owner Name (As shown on certificate of registration)
Address (As shown on registration certificate)
3.  For Authority Use Only
4.  Unit Identification 5.  Type
Unit Make Model  Serial Number Repair Modification
Airframe (As described in item 1 above)

Powerplant 
Propeller 
Appliance Type

Manufacture

6.  Conformity Statement
A.  Organisation Name and Address B.  Kind of Licence/Organisation C.  Certificate/Licence Number
0 Licensed (AMT) 0 A 0 P or 0 A/P
(For an AMO include the appropriate ratings issued for the major repair or modification)
0  Approved Maintenance Organisation
0  Manufacturer AMO
D.  I certify that the repair and/or modification 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 5 of the Model Regulations and that the information furnished herein is true and correct to the best of my knowledge.
Date
Signature of Authorised Individual
7.  Approval for Return To Service
Pursuant to the authority given persons specified below, the unit(s) identified in item 4 was inspected in the manner prescribed by the Director of the Civil Aviation Authority and is  0  APPROVED  0  REJECTED
BY
0  CAA Inspector
0 Inspection Authorisation
 Other (Specify)
0 Maintenance Organisation
0 Other
Date of Approval or Rejection
Certificate or Designation Number
Signature or Authorised Individual
CAA MR-MR&M Form (1/99)  Page 1
NOTICE
Weight and balance or operating limitation changes shall be entered in the appropriate aircraft record. A modification must be compatible with all previous modifications to assure continued conformity with the applicable airworthiness requirements.
8.  Description of Work Accomplished
(If more space is required, attach additional sheets. Identify each page with aircraft nationality and registration mark and date work completed.)
CAA MR-MR&M Form (1/99)  Page 2
Instructions For Completion Of Major Repair And Modification Form
Item 1 – Aircraft.  Information to complete the “make,” “model,” and “serial number” blocks will be found on the aircraft manufacturer’s identification plate. The “Nationality and Registration Mark” is the same as shown on Certificate of Aircraft Registration.
Item 2 – Owner.  Enter the aircraft owner’s complete name and address as show on the Certificate of Aircraft Registration.
Note:  When a major repair or modification is made to a spare part or appliance, items 1 and 2 will be left blank, and the original and duplicate copy of the from will remain with the part until such time as it is installed on an aircraft.  The person installing the part will then enter the required information in blocks 1 and 2, give the original of the form to the aircraft owner/operator, and forward the duplicate copy to the Authority within 48 hours after the work is inspected.
Item 3 – For Authority Use Only.  Approval may be indicated in Item 3 when the Authority determines that data to be used in performing a major modification or a major repair complies with accepted industry practices and all applicable [State] regulations.   Approval is indicated in one of the following methods:
1. Approval by examination of data only – one aircraft only:  “The data identified herein complies with the applicable airworthiness requirements and is approved for the above described aircraft, subject to conformity inspection by a person authorised in § 5.6.1.4.
2. Approval by physical inspection, demonstration, testing, etc. of the data and aircraft – one aircraft only”  “The modification or repair identified herein complies with the applicable airworthiness requirements and is approved for the above described aircraft, subject to conformity inspections by a person in § 5.6.1.4.”
3. Approval by examination of data only – duplication on identical aircraft.  “The modification identified herein complies with the applicable airworthiness requirements and is approved for duplication on identical aircraft make, model, and modified configuration by the original modifier.”
4. A signature in item 3, “For Authority Use Only,” indicates approval of the data described in that section for use in accomplishing the work described under item 8, “Description of the Work Accomplished.”  This signature does not indicate CAA approval of the work described under item 8 for return to service.
Item 4 – Unit Identification.  The information blocks under item 4 are used to identify the airframe, powerplant, propeller, or appliance repaired or modified.  It is only necessary to complete the blocks for the unit repaired or modified.
Item 5 – Type.  Enter a checkmark in the appropriate column to indicate if the unit was repaired or modified.
Item 6 – Conformity Statement
“A” – Agency’s Name and Address.  Enter name of the AMT, AMO or manufacturer accomplishing the repair or modification.  AMTs should enter their name and permanent mailing address.  Manufacturers and AMOs should enter the name and address under which they do business.
“B” – Kind of Licence/Organisation.  Check the appropriate box to indicate the type of person or organisation who performed the work.
“C” – Certificate/Licence Number.  AMT’s should enter their AMT licence number in this block.  AMO’s should enter their AMO certificate number and the rating or ratings under which the work was performed.  Manufacturers should enter their type production or Supplemental Type Certificate (STC) number.  Manufacturers of Technical Standard Orders (TSO) appliances modifying these appliances should enter the TSO number of the appliance modified.
“D” – Compliance Statement.  This space is used to certify that the repair or modification was made in accordance with [Part 5 of these regulations].  When work was performed or supervised by licensed AMT’s not employed by a manufacturer or AMO, they should enter the date the repair or modification was completed and sign their full name.  AMO’s are permitted to authorise persons in their employ to date and sign this conformity statement.
A signature in item 6, “Conformity Statement,” is a certification by the person performing the work that it was accomplished in accordance with applicable CAA and CAA-approved data.  The certification is only applicable to that work described under item 8, “Description of Work Accomplished.”  This signature does not indicate CAA approval of the work described under item 8 for return to service.
Item 7 – Approval for Return to Service.  MCAR Part 5 establishes the conditions under which major repairs and modifications to airframes, powerplants, propellers, and/or appliances may be approved for return to service. This portion of the form is used to indicate approval or rejection of the repair or modification of the unit involved and to identify the person or agency making the airworthiness inspection.  Check the “approved” or “rejected” box to indicate the finding.  Additionally, check the appropriate box to indicate who made the finding.  Use the box labeled “other” to indicate a finding by a person other than those listed.  Enter the date the finding was made.  The authorised person who made the finding should sign the form and enter the appropriate certificate or designation number.
1. Previously Approved Data.  The forms will be completed as instructed ensuring that Item 7 is completed as noted above.
2. Non-previously Approved Data.  The form will be completed as instructed, leaving item 7, “Approval for Return to Service” blank and both copies of the form will be sent to the Authority with supporting data.  When the CAA determines that the major repair or modification data complies with the applicable regulations and is in conformity with accepted industry practices, data approval will be recorded by entering an appropriate statement in item 3, “for CAA use only.”  Both forms and supporting data will be returned to the applicant who will complete item 7 “Approval for Return to Service.”  The applicant will give the original of the form, with its supporting data to the aircraft owner or operator and return the duplicate copy to the Authority for inclusion in the aircraft records at its Aircraft Registry.
A signature in item 7, “Approval for Return to Service,” does not signify CAA approval unless the box to the left of “CAA Inspector” has been checked.   The other persons listed in item 7 are authorised to “approve for return to service” if the repair or modification is accomplished using CAA-approved data, performed in accordance with MCAR Part 5, and found to conform.