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PART- 5 Doc No: HA-MOE-001

Issue: 01 Date: 06 Nov 2012Rev: 02Date: 18.06.2013Page 1

PART 5 APPENDIXES

TABLE OF CONTENTS PAGE

TABLE OF CONTENTS 1

.1 SA!PLE OF DOC"!ENTS 2

.2 LIST OF S"B#CONTRACTORS$ AS PER PART 1%.A.&'() %&

.3 LIST OF LINE !AINTENANCE LOCATIONS$ AS PER PART 1%.A.&'*) %&

.% LIST OF CONTRACTED OR+ANI,ATIONS AS PER PART 1%.A.&0 'a)'16) %&

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Page 2

5.1 SAMPLE OF DOCUMENTS

LIST OF FORMS

FORM TITLE

-A#1%.01 SERICEABLE TA+

-A#1%.02 "NSERICEABLE TA+

-A#1%.03 SCRAP CO!PONENT TA+

-A#1%.0% ROBBER/ LABEL

-A#1%.0 DO NOT TO"C- TA+

-A#1%.06 SPECIAL AND CALIBRATED TOOLS TA+

-A#1%.0& +RO"ND S"PPORT E"IP!ENT LIST

-A#1%.08 CONS"!ABLE PARTS LIFE LI!IT CONTROL LIST

-A#1%.0 CERTIFICATE OF RELEASE TO SERICE

-A#1%.10 !AINTENANCE OR ORDER

-A#1%.11 TOOL INSPECTION CARD

-A#1%.12 LOAN TOOL

-A#1%.13 "NSERICEABLE CO!PONENT LIST

-A#1%.1% SERICEABLE CO!PONENT LIST

-A#1%.1 SPECIAL AND CALIBRATED TOOLS !ONITORIN+ FOR!

-A#1%.16 SPECIAL AND CALIBRATED TOOLS RECORDS

-A#1%.1& OCC"RRENCE REPORT

-A#1%.18 "ARANTINE PARTS LIST

-A#1%.1 S-IFT -ANDOER FOR!-A#1%.20 EASA FOR! ONE

-A#1%.21 SCRAP PARTS LIST

-A#1%.22 DAIL/ REPORT FOR!

-A#1%.23 TEC-NICAL REPORT TO !AN"FACT"RER

-A#1%.2% TRAININ+ ORDER

-A#1%.2 A!BI+"O"S !AINTENANCE DATA REPORT

-A#1%.26 CRS STAFF LIST 4 CERTIFICATION STA!PS CONTROL

-A#1%.2& !AINTENANCE STAFF TRAININ+ RECORD

-A#1%.28CONTIN"ATION TRAININ+ PLAN 4 ALIDIT/ FOR PART 1%

CERTIFIED STAFF-A#1%.2 ONE OFF APPROAL A"T-ORI,ATION

-A#1%.30 NOTIFICATION OF ONE#OFF A"T-ORI,ATION ISS"ANCE

-A#1%.31APPLICATION FOR! FOR !AINTENANCE STAFF

NO!INATION AND RECORD

-A#1%.32 A"T-ORI,ATION CERTIFICATE

-A#1%.33 SCOPE OF A"T-ORI,ATION

-A#1%.3% CO!PETENCE ASSESS!ENT

-A#1%.3 E5CEPTIONAL S-ORT TER! E5TENSION RE"EST

-A#1%.36 ANN"AL A"DIT PLAN

-A#1%.3& NON CONFIR!IT/ REPORT

-A#1%.38 "ALIT/ A"DIT NOTIFICATION FOR!

-A#1%.3 A"DIT FOLLO "P

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Page 3

LIST OF FORMS (Continued

FORM TITLE

-A#1%.%0 RESERED

-A#1%.%1 LOANED PARTS RECORD

-A#1%.%2 DEFRRED CANCELLED ITE!S LIST

-A#1%.%3 FINAL C-EC AFTER !AINTENANCE

-A#1%.%% PERSONNEL SI+N LIST

-A#1%.% LO"BRICANTS AND C-E!ICAL PROD"CTS LIST

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Page %

SER!ICEABLE TAG (GREEN " #A-1$5.%1

HERMES AIRLINES

SERVICEABLE MATERIAL TAG HA- 145.01

R00.2012

DESCRIPTION: EXPIRATION DATE: QTY:

PART NUMBER: EASA/FAA FORM No.:

SERIAL NUMBER: BATCH NUMBER:

DATE: INSPECTOR:

REMOVED FROM:WORK ORDER No. :

EASA FORM ONE TRACK. NO. :

INSTALLED ON: AIRCRAFT TYPE:

WORK ORDER No.: ATL PAGE No.:

ENGINEER’S NAME: STATION: DATE:

STAMP: SIGNATURE:

UNSER!ICEABLE TAG (&ELLO' " #A-1$5.%

HERMES AIRLINES

UNSERVICEABLE MATERIAL TAG

HA- 145.02

R00.2012

DESCRIPTION:

PART NUMBER: SERIAL NUMBER:

REMOVED FROM: AIRCRAFT TYPE:

REASON FOR REMOVAL:


STAMP: SIGNATURE:

SCRAP COMPONENT TAG (RED " #A-1$5.%)

HERMES AIRLINES

SCRAP COMPONENT TAG HA-145.03

R00.2012

DESCRIPTION:

PART NUMBER: SERIAL NUMBER:

REMOVED FROM: AIRCRAFT TYPE:

AIRCRAFT REGISTRATION: ENGINE SERIAL No.:

ATL PAGE No.: LANDINGS:

REMOVED BY (BLOCK:


STAMP: SIGNATURE:

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Page

ROBBER& LABEL (ORANGE " #A-1$5.%$

HERMES AIRLINES

ROBBERY LABEL HA- 145.04

AUTHORIZATION FOR ROBBERY R00.2012

ROBBED I!"# PART NUMBER:

DESCRIPTION: SERIAL NUMBER:

ROBBED FROM: ROBBED TO SERVICE:

AIRCRAFT TYPE: AIRCRAFT TYPE:

AIRCRAFT REGISTRATION: AIRCRAFT REGISTRATION:

ENGINE TYPE: ENGINE TYPE:

ENGINE SERIAL No.: ENGINE SERIAL No.:

ATL PAGE No.: ATL PAGE No.:

TLT: LANDINGS: TLT: LANDINGS:

DATE: STATION: DATE: STATION:ORDERED BY: SIGNATURE:ORDER No.:

DO NOT TOUC# TAG (RED S#ADE " #A-1$5.%5

SPECIAL AND CALIBRATED TOOLS TAG (C&AN #A-1$5.%*

H E R M E S A I R L I N E S

SPECIAL AND CALIBRATED TOOLS TAG HA-145.06

R01.2013

MANUFACTURER: PART NUMBER: CHECKED BY:

SIGNATURE:

STAMP :

DESCRIPTION: SERIAL NUMBER:

CONDITION:

CHECKED: CALIBRATED:

DATE:

NEXT CHECK: CALIBRATION:

DATE:

H E R M E

S

A I R L I N E S

# A - 1 $ 5 . % 5

R 0 0 . 2

0 1

2

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Issue: 01 Date: 06 Nov 2012Rev: 00

Date:Page 6

GROUND SUPORT E+UIPMENT LIST

ITEM

No

E+UIPMENT

DESCRIPTIONLOCATION P,N S,N +T&

INSPECTE

D DATENEXT DUE DATE OUT SEGNATURE REMARS

FORM #A-1$5.%/

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Rev: 01Date: 08.0%.2013

Page &

FORM #A-1$5.%0

CONSUMABLE PARTS LIFE LIMIT CONTROL LIST

PART No DESCRIPTION STATION

DATE

SERIAL ,

BATC# , LOT

No

+T&COMPAN& ,

SUPPLIERA'B NO

RE+UEST ,

PO ,LOC MANUFACTURER

EASA,FAA

FORM

TRAING NO

OUT

GOI

NG

REMA

RS

BALA

NCE

EXPIR

DATE

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Rev: 01Date: 08.0%.2013

Page 8

FORM #A-1$5.%2

1.COUNTRY

GREECE

2.

CERTIFICATE OF RELEASE TO SERVICE3. Certificate Number

4. Approved Organiation Name and Addre!

HERMES AIRLINES Deligianni 2 Street, Alimos, 1!"#, At$ens Gree%e

". Operator # $npection %ate

&rom!

To!

'. (or) Order * Contract * $nvoice

&' Registration (' T)*e 1+'Ser' Nm-er 11' Hors 12' C)%les 1.' Engines s/n' 1!' A0

12.!

T)*e

S/N

1". (or) performed

1#. +,ception * Conceion * %eferred $tem

1'. -art 14" Reeae to /ervice

T$e nersigne Certi3ies t$at t$e 4or5 s*e%i3ie e6%e*t as ot$er4ise s*e%i3ie 4as %arrie ot in a%%oran%e 4it$ 0ART71!" an in res*e%t tot$at 4or5 t$e Air%ra3t is %onsiere rea) 3or release to ser8i%e' 9Re3': 0ART71!"'A'"+ 9-;'

10. Name 1. /ignature and /tamp 2. Approva Number 21. %ate

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MAINTENANCE

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Issue: 01 Date: 06 Nov 2012Rev: 00Date:Page 10

TOOL INSPECTION CARD

TOOL DESCRIPTION

PART NUMBER SERIAL NUMBER

No In34etion d6te Ne7t due Si8n6tu9e

FORM #A-1$5.11

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#ERMES AIRLINES LOANED TOOL RECORD

Man3a%trer Des%ri*tion 0art Nm-er Serial Nm-er

Cali-ration Stats Com*an) Loane Com*an) A**ro8al

DATA RECORD

Date Re%ei8e

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Date:Page 12

UNSER!ICEABLE COMPONENTS LIST

ITEM

NODATE DESCRIPTION P,N

S,N

BATC#

NO

LOCATION A,C REG A,C T&PE +T& NAME,SIGN. REMARS

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Date:Page 12

FORM #A-1$5.1)

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Date:Page 13

FORM #A-1$5.1$

SER!ICEABLE COMPONENTS LIST

ITEM

NODATE DESCRIPTION P,N

S,N

BATC#

NO

SUPPLIER A'B

No

EASA,FAA

FORM

TRAING

NO

+T& NAME,SIGN. REMARS

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Page 1%

S0ECIAL AND CALI@RATED TOOLS MONITORING FORM

HERMES AIRLINES

DESCRI0TION0ARTNo'

SERIALNo'

REFERENCENo'

CALI@RATIONDATE

DE DATE REMAR=S

UNSERVICEABLE CONDITION REASON

FORM #A-1$5.15

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Page 1

S0ECIAL AND CALI@RATED TOOLS RECORDS

HERMES AIRLINES

%+/CR$-T$ON! 5O%+6!

6AORATORY R+&+R+NC+! -ART No.! /+R$A6 No.!

5ANU&ACTUR+R! O(N+R!

R+&+R+NC+ %OCU5+NT/! U/+R!

CA6$RAT$ON &R+7U+NCY! RAN8+!

CALI@RATION HISTOR> CONTRACTOR EASA 0ART 1!"CONTRACTORS

HCAA A00ROVEDREFERENCE STANDARDS

SIGNED @>6A/T

N+9T%U+

C+RT$&$CAT+

REMAR=S

FORM #A-1$5.1*

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Page 16

OCCRRENCE RE0ORT TO HCAA

OCCRRENCE RE0ORT FORM

1' T$is Form is to -e 3ille 3rom t$e nersigne an mst -e s-mitte to t$e HCAA in %aseo3 serios e3e%t to t$e air3rame, engine or %om*onent'

2' DATE:6OCAT$ON!O-+RATOR!

R+8$/TRAT$ONNo!

A$RCRA&T TY-+ /*N T/O T/N

A$R&RA5+

-O(R -6ANT

.' S0ECIFIC AFFECTED ITEM'NOMENCLATRE 0/N S/N TSO TSN

!' OCCRRENCE DETAILED DESCRI0TION

"' 0RO@A@LE CASE AND SGGESTIVE ACTION FOR FRTHER AVOIDANCE

#' COM0AN>: ADDRESS:

TEL: FA:

HERMES AIRLINESDELIGIANNI 2 ALIMOS++.+ 211 1" 2+ .+++.+ 21+ (( .( &"+

' A00LICANT NAME: DATE: LICENSE No:

SIGNATRE:

FORM #A-1$5.1/

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Rev: 00Date:

Page 1&

FORM #A-1$5.10

+UARANTINE PARTS FORM

ITEM

NO DATE DESCRIPTION P,N

S,N

BATC#NO

SUPPLIER A'B No

EASA,FAA

FORMTRAING

NO

+T& NAME,SIGN. REMARS

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HANDOVER FORMHERMES AIRLINES

:

SHIFT

'! : 1"! 1"! ; 23! 23! ;'!

MENTS:

NAMES AND SIGNATRES

T OFF:

T ON:

FORM #A-1$5.12

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Rev: 00Date:

Page 1

FORM #A-1$5.%

1.

HELLENIC RE0@LICCIVIL AVIATION

ATHORIT>

2.

ATHORISED RELEASE CERTIFICATEEASA FORM 1

3. &orm Trac)ing Number

4. Approved Organiation Name and Addre! HERMES AIRLINESDeligianni 2 Street, Alimos, 1!"#, At$ens Gree%e

". (or) Order * Contract * $nvoice

#.$tem

'. %ecription 0. -art No. . 7uantit 1. /eria * atc< No. 11. /tatu * (or)

12. Remar)

13a. Certifie t

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SCRA0 0ARTS LIST

HERMES AIRLINES

/TAT$ON! 5ONTB!

%+/CR$-T$ON -ART NU5+R %AT+ R+5O+%+N8$N++R/$8NATUR+

NOTE: /CRA- part are detroed a reDuired> under 7uait 5anagerE reponibiit.

FORM #A-1$5.1

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Issue: 01 Date: 06 Nov 2012Rev: 0Date: 2.08.201%Page 21

DAIL& REPORT

DATE STATION AC REG. STATION ENG.

F7t. No: Te9. De7a: es ;o Reaso;!








A,C TEC#. INFORMATION

STATION INFORMATION

MATERIAL RE+UIRED P,N +UANT

MATERIAL USED P,N S,N +UANT

DDL , MEL , STATUSDDL NO

LOG PAGEDESCRIPTION OF REPAIR

PART RE+

(P,NDUE DATE

FORM #A-1$5.

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TECHNICAL REPORT TO MANUFACTURERCo:46n; Ai996

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HERMES AIRLINESLINE MAINTENANCE DE0ARTMENT

TRAINING ORDER

DATE:

CORSE TITLE:

INSTRCTIONS NAME 0OSITION/ TITLE

NO FIRST NAME SRNAME RAN= LICENSE No NATIONALIT>

1

2

.

ORGANIER

LOCATION

DRATION

DATE

6ine 5aintenance 5anager!

Notification! $ntructor> Trainee.Circuation! CA5O 5anager> 7uait 5anager> Accountabe 5anager.

FORM #A-1$5.$

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Issue: 01 Date: 06 Nov 2012Rev: 00Date:Page 2%

HERMES AIRLINES

Am-igos Maintenan%e Data Re*ort

%ate! Ref. No!

5aintenance %ata!%ecription of data * page

-

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Rev: 01Date: 08.0%.2013

Page 2

CRS STAFF LIST CERTIFICATION STAM0S CONTROLHERMES AIRLINES

STAM0 NO' ANDSAM0LE

A/C T>0E ISSED TO 9NAME; DATEDATE

REMOVEDREMAR=S

SIGNATRE

Re8ise ate: 1+/12/12 FORM #A-1$5.*

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MAINTENANCE STAFF TRAINING RECORD

HERMES AIRLINES

NAME:

ORDER NO'IF A00LICA@LE

CORSEDESCRI0TION

INITIAL RECR' DATE SIGN

FORM #A-1$5./

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Rev: 00Date:

Page 2&

CONTINUATION TRAINING PLAN !ALIDIT& FOR PART 1$5 CERTIFIED STAFF

FORM #A-1$5.0

NAME AUTHORIZATION

Expiration Dates

FUEL TANK

SAFETY

HUMAN

FACTORS E.W.I.S.

EASA

LEGISLATION

MOE

PROCEDURES

QUALITY

SYSTEM

LICENSE

VALIDITY

AUTHORIZ.

VALIDITY

1

2

3

%

6

&

8

10

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ONE OFF APPRO!AL AUT#ORIATION#CAA APPRO!AL REF. EL.1$5

Auto9i6tion No.

1. Lo6tion . P9oide9 ). A449o6= Re

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NOTIFICATION OF ONE-OFF AUTHORIZATION

ISSUANCE

R$%: (EC &'&/&'')* +,.A.)'(-(,* AMC +,.A.)'-(,((

+. N0$ o% P12 +, AMO:

&. P12 +, AMO A331o45 No:

). P12 +, MOE O6$7O8 A92o1;2o6 P1o

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FORM #A-1$5.)%

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APPLICATION FORM FOR MAINTENANCE STAFF

NOMINATION AND RECORD

HERMES AIRLINES

NA5+! %AT+ O& $RTB!

BO5+ A%%R+//! NAT$ONA6$TY!T+6+-BON+! FO T$T6+!

+5-6OY5+NT %AT+! CO5-ANY NU5+R!

@ASIC TRAINING T>0E TRAINING

Coure Tite -rovider 7uaification%ate

ObtainedCoure

Tite-rovider

7uaification

%ate Obtained

CONT$NUAT$ON TRA$N$N8

1 3

2 4

E0ERIENCE

T)*e o3 E6*erien%e Com*an) From To 0osition

LICENSES/RATINGS

6$C+N/+ TY-+*NR 1 2 A$RCRA&T TY-+*RAT$N8/ 1 2

?ALIFICATIONS RELEVANT TO THE A00ROVAL

SCO0E OF THE ATHORIATION

NOMINATION A00L>ING FOR:

Aircraft Tpe! P145$$:

DETAILS OF 0ERSON RECOMMENDING THIS A00LICATION

&u Name! -oition! S6291$: D2$:

DECLARATION OF 0ART 1!" 9AMO; MAINTENANCE MANAGER

T

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Issue: 01 Date: 06 Nov 2012Rev: 01Date: 08.0%.2013Page 31

ATHORIATION CERTIFICATE

HERMES AIRLINES EL'1!"BBATHORIATION DOCMENT:

Name

6icene No

Aut

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SCO0E OF ATHORIATION

HERMES AIRLINES 0ART71!" 9EL'1!"BB;

MAINTENANCE STAFF ATHORIATION No:

NA5+

/-+C$A6$TY

6$C+N/+ No

Ta7 too7s a

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NoS@JECT

STARTDATE

FINISHDATE

0ERFORMANCERESLTS

NETDE

ASSESSORSSIGNATRE

FINAL ASSESSMENT@EFORE DTIES ASSIGNEMENT

(e> t e,amined t

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Issue: 01 Date: 06 Nov 2012Rev: 01Date: 08.0%.2013Page 3%

P68e o< )

FORM #A-1$5.)$

COMPETENCE ASSESSMENT

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NAME:VERIFICATION

>ES/NO0ART M

?ALIT>MANAGER

Abiit to determine reDuired Duaification for ta)performance

Abiit to identif and rectif e,iting and potentiaunafe condition

Abiit to confirm proper accompi prioritie ta) and reportdicrepancie

Abiit to proce t contro andbe famiiar =it< reDuired tooing and*or eDuipment

AdeDuate communication and iterac )i

REMAR=S:

1. -+R/ON R+/-ON/$6+ &OR TB+ -ROC+// : 7uait 5anager 1. (B+N A//+//5+NT /BOU6% TAJ+ -6AC+ ; efore a ne= CR/ i iued*e,tended or CAT KAL

5+CBAN$C Aut

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Issue: 01 Date: 06 Nov2012Rev: 00Date:

Page 3#

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Issue: 01 Date: 06 Nov2012Rev: 00Date:

Page 3'

AIRCRAFT ENGINE / A0 E?I0MENT

A/C T)*e :

Registration :

C$e%5 :

Toleran%e se :

Dealine :

Designation

T)*e :

S/N :

0os/a8ion :

ReKest :

Des%ri*tion :

CHEC= DESIGNATION INTERVAL REF' TOOLING

S*e%i3i% Monitoring >es No

RENSEIGNEMENTS / STATISTI?ES FLI GHT HORS FLI GHT C>CLES CALENDAR

ReKeste 0otential :

A**ro8e 0otential: 9Com*lete -) At$orities;

Latest te%$log' :

F/H an F/C sin%e last RC A00ROVED

DEADLINE :

AD STATS :

MEL/HIL STATS :

AIRLINE COM0ETENT ATHORIT>

1!" AMO MANAGER CAMO MANAGER ?ALIT> MANAGER HCAA

Date: Date: Date: Date:

FORM #A-1$5.)5

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Issue: 01 Date: 06 Nov

2012Rev: 00

Date:

Page 3'

071!" ANNAL ADIT 0LAN 3or t$e >EAR 2+''&OR5 BA:14".3#$//U+! 1* # Nov 212R+!

SECTION OF ADITJAN FE@ MAR A0RIL MA> JN JL AG SE0 OCT NOV DEC

MO?A7+17 FACILIT>/ 0ERSONNEL RE?IREMENTS

MO?A7+27 CERTIF>ING STAFF7 E?I0MENT, TOOLSAND MATERIAL

MO?A7+.7 ACCE0TANCE OF COM0ONENTS7MAINTENANCE DATA

MO?A7+!7 0RODCTION 0LANNING7 CERTIFICATIONOF MAINTENANCE

MO?A7+"7 MAINTENANCE RECORDS7 OCCRRENCERE0ORTING

MO?A7+#7 SAFET> ?ALIT> 0OLIC>7 M'O'E70RIVILEDGES/ LIMITATION/ CHANGES/ OF THEORGANIATIONTION7 COM0LIANCE IA< THE M'O'E'

MO?A7+7 0RODCT SAM0LING7 9AIRCRAFT AND SAFET> 0OLIC>

MO?A711 LINE STATIONS

RM #A.1$5.)*

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Page 3

NON7CONFORMIT> RE0ORT&OR5 BA.14".3'$ue! 1* # Nov 212Rev.!

No of Audit! ReDuirement ref. ! Area of Audit * Tite!

%ate*-ace of iue of t /ign. Auditor @Name> %ate> /ign.

0art . ; Corrective action pan !

0art ! ; Root caue anai!

Action Ta)en b @Name> %ate> /ign. ! ACC+-T+% b 7uait 5anager! Y+/ NOM &oo= Up! Y+/ NO M $f ENoEE Note t /ign.

Accountabe 5anager @Notified for NCR

@Name> %ate> /ign.

Accountabe 5anager @Notified for Coure Corrective action

@Name> %ate> /ign.

FORM #A-1$5.)/

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Page 3

?ALIT> ADIT7INS0ECTIONNOTIFICATION FORM

&OR5 BA.14".30$ue! 1* # Nov 212Rev.!

%epartment*Compan! Au*>t I;set>o; Reoo; T>t7e:

Reponibe -ot Boder! Loat>o;: Au*>t I;set>o; P7a;;e* Date:

S%o*e o3 t$e Ait / Ins*e%tion:

NOTIFICATION

%ear 5anager> peae be informed t

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Issue: 01 Date: 06 Nov 2012Rev: 00Date:Page %0

ADIT FOLLOEAR B'

&OR5 BA.14".3$ue! 1* # Nov 212Rev.!

071!" DE0ARTMENT

AU%$TRef> No.

&UNCT$ON/ * Auditor %ate of Audit

&oo= Up%ate

Coure%ate

Accepted 7.5.

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RESER!ED

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HERMES AIRLINESLOANED 0ARTS RECORD

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Cstomer A**ro8al

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Issue: 01 Date: 06 Nov 2012Rev: 01Date: 08.0%.2013Page %%

FINAL CHEC AFTER MAINTENANCE

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Issue: 01 Date: 06 Nov 2012Rev: 02Date: 08.0.2013Page %

PER!ONNEL !I"N LI!T

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ITEM DESCRI0TION 0/N @ATCH, LOT ?T> CoC LOC E0' DATE 0'OINCOMING AND OTGOING LIST

OT A/C @AL' DATE

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Issue: 01 Date: 06 Nov 2012Rev: 02Date: 18.06.2013Page %&

5.1 LIST OF SUB-CONTRACTORS AS PER PART 1$5.A./5 (?

7NIL7 7NIL7

5. LIST OF LINE MAINTENANCE LOCATIONS AS PER PART 1$5.A./5(d

A. AT-ENS INTERNATIONAL AIRPORT$ SPATA +REECE '!a>; L>;e Stat>o;)

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Moe p 5 Rev 5 Aap Rev 6