Production Part Approval

Performance Test Results

Par t Su b mi ss ion W a rra nt

Part Name P art N umbe r

Saf ety a nd/or
Go ver nment R egu a
l ti
o n Yes N o Eng n
i eeri ng Dr aw i ng C hang e Lev el Dat ed
Ad di ti
o nal Eng n
i eer i
ng Ch a
nge s Dat ed
Sho wn o n D raw i ng N o. Pu rch ase Or der No . W ei g ht (kg)
Che cki
ng A id No . Eng n
i eeri ng Ch ange Level Dat ed

SUPP LIE R M A N UF ACT UR

IN G IN FORM A T ION S UB M ISS ION INF ORM ATIO N

Dimens i ona l Mate ri al s /Fu nc ti ona l App ear anc e

S up p lier Na me &S u p p l
ie r Co d e
C usto me r N ame/D i vi si on

B uyer /B uyer Co de
S t re et Ad d re ss

A ppl i cat on
i
Ci t y S ta te Zip

No te : Do e s th is p a rt co n t ain an y r es t ri cte d o r r ep o rt ab le su bs tan ce s YES N O

Ar e p l ast ic p ar t s id en ti fie d wit h app r op r iat e IS O m ar k in g c
o d es YES N O

REA S ON FOR S U BM IS SION

In i ti al Subm i s s i on Cha nge to O p ti onal C ons t ruc t i

o n or Mate ri al
En gi n eer i
n g C h ange (s) Sub- Sup pl
i er or Mate r i al Sou rce C han ge
To oli n g: Tr ans f er , R epl ac ement , R ef u
rb sh
i me nt o r a ddi ti ona l Cha nge n
i Par t Pr oc es s i ng
C orr ec ti on of D i s cr epa nc y Par t Pr odu ce d at Ad di ti onal Loc at i on
To ol
in g Ina c ti ve > 1 year O the r - Pl eas e s pe cif y

REQU ES TED S UB M ISS ION LE VE L ( C h eck o ne )

Leve l 1 - W ar ra nt o nly (a nd f or d es i
gnate d ap pear anc e i te m s, an Ap pear anc e A ppr oval R epor t) s ubmi tt ed to c us t omer .
Leve l 2 - W ar ra nt wi th pr oduc t sa m ples and im
l i ted s uppor ti ng dat a s ubmi tt ed to c us t omer .
Leve l 3 - W ar ra nt wi th pr oduc t sa m pl
es and co m ple te su ppor ti ng dat a s ubmi tt ed t o c us t omer.
Leve l 4 - W ar ra nt a nd ot her req ui reme nts as d efi ne d by c us t omer .
Leve l 5 - W ar ra nt wi th pr oduc t sa mpl
es and co mpl
e te su ppor ti ng dat a rev e
i wed at s upp i er '
l s ma nufa c tur i ng l oc ati o n.

SUBM IS SION RESUL TS

Th e re s u ts
l fo r d ime n si on al me a s ure m en ts m a teri a la nd fu nc tio na lt es ts a pp e a ran c e c ri
te ri a s tatis ti
c a lp ro c es s p a ck a g e
Th e se re su lts m ee t a l dra wi ng an d s p e ci fi ca tio n re qu i re me n t s:
YES NO ( I
f "N O" - Ex pl anati on Re qui red )
Mo d
l / C avi ty / Pr oducti on Pr ocess

DECL ARA T ION

I he re by a ffi rm th a tt he sa m ple sre pr es e nte d b y th is wa rran t are rep re s en ta ti
v e o fo u r pa rt s , h av e b e e n m ad e to th e a p plica b e
l
P ro du c t i o n P a rt Ap p r
o va lP roce s s M a n ua l3 rd Ed i t i o n Re q u i re m en ts . Ifu rt h er wa rra nt th es e s a m ple s we re
p ro d u ce d a t the pr o du c ti
o n rate o f /8 h o u rs . I ha v e n o te d a n y d e v ia ti
o ns fro m th i
s de c l
a ra t i o n b elo w.

EXP LA NA TION /COMME NTS:

ORGANIZATION: PART NUMBER:

SUPPLIER/VENDOR CODE: PART NAME:
MATERIAL SUPPLIER: DESIGN RECORD CHANGE LEVEL:
*CUSTOMER SPECIFIED SUPPLIER/VENDOR CODE ENGINEERING CHANGE DOCUMENTS:
*If source approval is req'd, include the Supplier (Source) & Customer assigned code.

SPECIFICATION / TEST QTY. NOT

TEST SPECIFICATION / REV / DATE LIMITS DATE TESTED SUPPLIER TEST RESULTS (DATA) / TEST CONDITIONS OK OK

Blanket statements of conformance are unacceptable for any test results.

MARCH CFG-1005 SIGNATURE TITLE DATE

2006