Air Works India Engineering Pvt Ltd

DGCA approved CAR 145 Organization

Breath Analyzer Test ±Self Declaration Form

Sl. No. 144435

UNDERTAKING OF AVIATION PERSONNEL

Note: This undertaking is based on DGCA Order DGCA-15031/4/2020-DAS dated 13/05/2021. Further, this order is purely
temporary measure in view of COVID-19, which will be reviewed from time to time by DGCA, India.

Warning : In case of violation of the undertaking, the License/Approval will be suspended for a period of THREE years.

I, ISHWAR VAYKOS (name),

JUNIOR TECHNICIAN (designation),

Employee No. A01247 holding valid DGCA license / Approval Holder no.

or Approval issued by any other Authority to facilitate operation at airport HOSUR

do hereby report for the duty to operate flight (s)

in the capacity of MAINTENANCE (nature of duty)

on date 02/07/2021 07:37 AM at HOSUR station/airport.

Further I do declare that:

1. I am not under the influence of Alcohol.

2. I have not consumed Alcohol/ Psychoactive substance in the last 12 Hours from the time of
reporting for the duty.

Name of Aviation Personnel : ISHWAR VAYKOS

Date of Declaration (dd/mm/yyyy) : 02/07/2021

Signature of Aviation Personnel :

Form No. AWCMRO/Quality/ F038A , Rev. 2 dtd May. 2021 Page 1 of 1