MOD Format 755(SM5)
(Revised Jul 15)
OFFICIAL*
Service Modification Initiation Certificate SM Ser No.
1. Authority/PT
2. Aircraft Type/Mark/Main Equipment
3. Description
4. Category
Safety/Operational/Engineering*
5. Provisional Programme and Members
Requirement:
a.
Design Organization selected to design SM is:
b.
Trial Unit:
1.
Unit selected to install trial SM is:
2.
Flight Trial Unit Tasked:
3.
Person nominated to sign-off TI (SM6)
c.
Aircraft to be positioned at TI Unit for trial installation
on (Date)
d.
Flight Trials planned to commence on (Date):
e.
Proof Installation Unit selected to install SM is:
f.
Proof Installation is planned to commence on:
g.
Clearance Meeting planned for:
h.
Fleet embodiment planned to commence on:
i.
Number of aircraft to be embodied:
j.
Embodiment unit(s)/locations:
k.
Number of SM kits plus spares (excluding TI) required
are:
l.
SM kit manufacturer:
m.
Additional Requirements:
1.
2.
3.
* Select/delete as applicable
OFFICIAL*
(SM5) 1-2
OFFICIAL*
SM Ser No 6. Summary of Initiation Meeting/Review
An initiation meeting/review was conducted and all aspects of the SM Initiation have been considered. The
following have been accepted subject to the reservations listed below which are to be incorporated into the
SM design:
Remarks:
a.
Outline Design.
b.
SSQ.
c.
DSML.
d.
Training Issues.
e.
Technical Information.
f.
Reservations.
g.
Where an Initiation Meeting was held the minutes are/are not* attached to this certificate.
7. RTSA Statement
Having reviewed this proposal - no further evidence required/the following evidence is to be made available
to assess the effect of the proposed SM on the aircraft RTS is *.
Name:
Signature:
Post:
Rank/Grade:
Tel No:
Date:
8. PT Authority to Initiate SM
Sponsorship and financial approval for the design, production and embodiment of this SM has been given.
[Trial Unit] are authorized to commence with the TI of this SM and demand parts for the TI, quoting
this certificate as the authority.
Competent person with the appropriate airworthiness delegation.
Name:
Signature:
Post:
Rank/Grade:
Tel No:
Date:
* Select/delete as applicable
OFFICIAL*
(SM5) 2-2