Certifying staff assessment sheet

Surname, Name:
Certifying staff category:
Airbus Boeing Boeing Boeing Airbus
Ratings: 319/20/21 767-2/3 737-3/4/5 737-6/7/8/9 310-2/3
Component Other

Date:

Description Yes No Remarks

Maintenance experience
National licence
Maintenance logbook:
Basic education Diploma:
Type training/Specialized training:
On-the-job-training:
Human Factors and Av.Legislation
training:
Continuation training including:
MOE/Procedures:
EASA regulations:
CDCCL training:
EWIS training:
Human Factor issues:
Duties and responsibilities relevant to the
position

English language: Reading and Writing

understanding

Result Passed Not passed

A qualification assessment has been successfully passed based on the decision of

Qualification Commission

Mr. ___________________ has been found to be properly qualified to exercise/to

renew the privileges of a category ___________certifying staff to perform the
maintenance of________________________________________________
aircraft/component (specify if other).

Quality assurance department specialist__________________(signature, name)

Issue 4Rev. 0 Part-145 Approval Ref. EASA.145.0130 Form 3.4