Production Part Approval

Dimensional Test Results

Part Submission Warrant

Par t Name Par t Number

Saf ety and/or
Gov er nm ent Regulation Yes No Engineer ing Dr aw ing Change Lev el Dated
A dditional Engineer ing Changes Dated
Show n on Dr aw ing No. Pur c has e Or der No. Weight ( kg)
Chec king A id No. Engineer ing Change Lev el Dated

SUPPL IER M ANUFACT URING INFORM AT ION SUBM ISSION INFORM AT ION

Dimensional Materials/ Functional Appearance

Supplier Name & Supplier C ode
Cus tomer Name/Div is ion

Buy er /Buy er Code

Street A ddress

A pplic ation
C ity State Zip

No t e : Do e s t h is p ar t co n t ain an y r e s t r ict e d or r e p o r t ab le s u b s t an ce s YES NO

Ar e p las t ic p ar t s id e n t if ie d w it h ap p r o p r iat e ISO m ar k in g co d e s YES NO

REASON FOR SUBM ISSION

I nitial Submission Change to Optional Construction or Material
Engineering Change(s) Sub-Supplier or Material Source Change
Tooling: Transfer, Replacement, Refurbishment or additional Change in Part Processing
Correction of Discrepancy Part Produced at Additional Location
Tooling I nactive > 1 year Other - Please specify

REQUEST ED SUBM ISSION LEVEL ( Ch e ck 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.

SUBM ISSION RESUL T S

T he res ults fo r dimens io nal meas urements material and func tio nal tes ts appearanc e c riteria s tatis tic al pro c es s pac k age

T hes e res ults meet all drawing and s pec ific atio n requirements : YES NO (If "NO" - Ex planation Requir ed)
Mold / Cav ity / Pr oduc tion Pr oc es s

DECL ARAT ION

I hereby affirm that the s amples repres ented by this warrant are repres entativ e o f o ur parts , hav e been made to the applic able
P ro duc tio n P art A ppro v al P ro c es s M anual 3rd E ditio n R equirements . I further warrant thes e s amples were
pro duc ed at the pro duc tio n rate o f / 8 ho urs . I hav e no ted any dev iatio ns fro m this dec laratio n belo w.

EXPLA NA TION/COMMENTS:

ORGANIZATION: PART NUMBER:

SUPPLIER/VENDOR CODE: PART NAME:
NAME OF INSPECTION FACILITY: DESIGN RECORD CHANGE LEVEL:
ENGINEERING CHANGE DOCUMENTS:

SPECIFICATION / TEST QTY. NOT

ITEM DIMENSION / SPECIFICATION LIMITS DATE TESTED ORGANIZATION MEASUREMENT RESULTS (DATA) OK OK
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Blanket statements of conformance are unacceptable for any test results.

MARCH CFG-1003 SIGNATURE TITLE DATE

2006