PART SUBMISSION WARRANT

PART SUBMISSION WARRANT

Part Submission Warrant Part Name Shown on Drawing No. Engineering Change Level Additional Engineering Changes Safety and /or Government Regulation Yes No Checking Aid Purchase Order No. Engineering Change Level CUSTOMER SUBMITTAL INFORMATION × Dimensional Organization Name & Supplier/Vendor Code Customer Name/Division Street Address Buyer/Buyer Code Application City Region Postal Code Country Materials/Functional Appearance Part Number Org. Part Number Dated Dated Weight Dated kg

(Average of 10 pcs in 4 decimal point)

Checking Aid No. ORGANIZATION MANUFACTURING INFORMATION

MATERIALS REPORTING Has customer-required Substance of Concern information been reported Submitted by IMDS or other customer format:

Yes

No

n/a

Are polymeric part identified with appropriate ISO marking codes

Yes

No

n/a

REASON FOR SUBMISSION ( Check at least one ) Initial Submission Engineering Change(s) Tooling: Transfer, Replacement, Refurbishment, or additional Correction of Discrepancy Tooling Inactive > than 1 year REQUESTED SUBMISSION LEVEL (Check one) Level 1 - Warrant only (and for designated appearance items, an Appearance Approval Report) submitted to customer. Level 2 - Warrant with product samples and limited supporting data submitted to customer. Level 3 - Warrant with product samples and complete supporting data submitted to customer. Level 4 - Warrant and other requirements as defined by customer. Level 5 - Warrant with product samples and complete supporting data reviewed at supplier's manufacturing location. SUBMISSION RESULTS The results for dimensional measurements material and functional tests and These results meet all drawing and specification requirements: Yes No Mold/Cavity/Production Process DECLARATION I hereby affirm that the samples represented by this warrant are representative of our parts and have been made to the applicable Production Part Approval Process Manual 4th Edition Requirements. I further affirm that these samples were produced at the production rate of / hours. I have noted any deviation from this declaration below : EXPLANATION/COMMENTS: appearance criteria statistical process package (If "No" - Explanation Required) Change to Optional Construction or Material Sub-Supplier or Material Source Change Change in Part Processing Parts Produced at Additional Location Other - please specify

Is each Customer Tool properly tagged and numbered? Organization Authorized Signature Print Name Title E Mail E- mail

×

Yes

No Date Phone No. FAX No.

FOR CUSTOMER USE ONLY (IF APPLICABLE) Part Warrant Disposition: Approved Rejected Other

Customer Signature Print Name

Date Customer Tracking Number (optional)

Procedure QUA 014 Appendix 7.1 QR-PE-019/A

REV 2

PART SUBMISSION WARRANT

Part Submission Warrant

Procedure QUA 014 Appendix 7.1QR-PE-019/A

REV 2

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