Name of Organisation: Location(s) of Organisation: Date: Note: In completing of this form, the following paragraphs of Part 21 articles need to be taken into account Part 21.A.4; Part 21.A.133; Part 21.A.151; Part 21.A.163 Accurate completion of the list is essential being the input for POA eligibility determination. Detailed description Identify Aviation Means of compliance with Direct State which eligibility criteria in List and location of major of Terms of Approval the Holder Authority 21.A.133 and 21.A.4 Delivery GM 21.A.133(a) are applicable customers which require to be applied for: of the approving (consult AMC 21.A.4; AMC Authorisation Indicate how eligibility criteria in this GM EASA Form 1 are satisfied (part / appliance for approved the Design N0. 1 & 2 to 21.A.133(b) and to be granted design (c) by Holder of aircraft type….) Make reference to and provide copy of approved arrangements design (Y/N)
Name of Organisation: Location(s) of Organisation: Date: Note: In completing of this form, the following paragraphs of Part 21 articles need to be taken into account Part 21.A.4; Part 21.A.133; Part 21.A.151; Part 21.A.163 Accurate completion of the list is essential being the input for POA eligibility determination. Detailed description of Terms of Approval to be applied for: (part / appliance for aircraft type….) Identify the Holder of the approved design Aviation Authority approving the Design Means of compliance with 21.A.133 and 21.A.4 (consult AMC 21.A.4; AMC N0. 1 & 2 to 21.A.133(b) and (c) Make reference to and provide copy of arrangements Direct Delivery Authorisation to be granted by Holder of approved design (Y/N) State which eligibility criteria in GM 21.A.133(a) are applicable Indicate how eligibility criteria in this GM are satisfied List and location of major customers which require EASA Form 1
FO.POA_.00004%20POA%20eligibility%20evaluation%20checklist.docx