Form SRG 1705 (EASA Form 4) Issue 05, April 2020
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EASA Form
4 - Details of Nominated Personnel - Airworthiness
Organisations
This form can be completed online, then printed and signed. If filled in by hand, please use black or dark blue ink.
Details of Nominated Personnel required to be accepted as specified in:
Please tick appropriate box (*)
Part 21
.A.145
Part 145.A.30
Part 147.A.105 Part 145.A.36
(AR / ARC Signatory)
Part M.A.706
Part M.A.706(i)
(ARC Extension Only)
Part T.A.706
Part M.A.707
(AR / ARC Signatory)
Part M.A.606
Part M.A.607
(AR / ARC Signatory)
1. Name of
Organisation: ...................................................................................................................................................
2. Approval Reference: ......................................................................................................................................................
3. Name: .............................................................................................................................................................................
4. Emai
l Address: ...............................................................................................................................................................
5. Telephone Number: ........................................................................................................................................................
6. Position / Title: ...............................................................................................................................................................
7. Qualifications relevant to Nominated Position (Item 6)
Example: B XXX (Hons) XXXXXXX or EASA Part 66 BXX Licence or Part M introduction 2 day course (mention training provider)
8. Work Experience relevant to Nominated Position (Item 6)
Example: 2009 – 2014 Smiths Engineering (UK.145.01234) – Maintenance Manager
Form SRG 1705 (EASA Form 4) Issue 05, April 2020
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Additional Supporting Information:
10. Other nominated EASA Form 4 positions currently held and other significant Activities undertaken
(include name and approval number of organisation):
Example: Jones Engineering (UK.21G.01234) – Production Manager
11. Manhour/Resource Plan
The applicant should provide a Man-hour/Resource Plan with this application to demonstrate the applicant has
sufficient capacity to carry out the role in an effective manner. This should include all activities mentioned in block 10.
12. Accountable Managers Declaration
I declare that the above-named person nominated as a Postholder within my organisation has been found to be
competent to carry out the role in accordance with the roles & responsibilities as described in the Organisations
Exposition. (**)
Si
gnature ……………………………………………………………….. Date ……………………………………………………….
(**) FALSE REPRESENTATION STATEMENT It is an offence under Article 256 of the Air Navigation Order 2016 to make, with intent to deceive, any
false representation the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or other document. This
offence is punishable on summary conviction by a fine and or up to two years imprisonment.
Note: The information submitted will be stored on a database and is restricted to authorised persons in accordance with the Data Protection Act 1998.
CAA use only
Name and signature of authorised CAA staff member accepting this person:
Si
gnature .............................................................................. Date .....................................................................................
Na
me .................................................................................... Office ...................................................................................
Once authorised, a copy of the completed EASA Form 4 must be returned to the nominee.
9. Applicant’s Declaration
I declare that I meet the requirements for qualification, knowledge and experience as details in the applicable EASA
regulation (*) and I have sufficient capacity to complete this role as described in the roles and responsibilities section of the
Organisations Exposition. (**)
Signature ……………………………………………………………….. Date ……………………………………………………….
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