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┃          ┃類    ┃口其他                                                            ┃
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┃維修或    ┃經檢查，該航空器在限制使用條件下處于適航狀態。                            ┃
┃制造單    ┃                                                                          ┃
┃位聲明    ┃負責人（簽字）    單位（蓋章）                                            ┃
┃          ┃                                                                          ┃
┃（適用于  ┃                                                                          ┃
┃第Ⅲ類）  ┃執照號號    日    期                                                      ┃
┃          ┃                                                                          ┃
┃          ┃                                                                          ┃
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┃  生      ┃生產依據：                                                                ┃
┃  產      ┃    口生產許可證，證件號碼                                                ┃
┃          ┃                                                                          ┃
　
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