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BLOCK CAPITALS using black or dark blue ink. Unique No. (to be completed by CAA) Please read attached Guidance Notes before completing this form. This form is to be used by both Aircraft Engineers and Flight Crew. FALSE REPRESENTATION STATEMENT It is an offence under Article 231 of the Air Navigation Order 2009 to make, with intent to deceive, any false representation for the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or oth.

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