Egba Split-Clamps Limited

Form 107: Corrective/Preventive Action Request

Nonconformity/Potential Nonconformity Identified by:
Project/Place of Occurrence:
Date/Time:

Description of Nonconformity/Potential Nonconformity:

Root Cause(s):
Signed: Date:..

Immediate Action(Correction):
Signed:

Date:

Corrective /Preventive Action Plan:

Signed: Date:..

Customer Disposition (if any):

Signed: Date:..

Corrective /Preventive Action Taken:

Signed: Date:..

Close out( Department/Unit Head Follow up):

:
Signed: Date:..

Form 107, Rev. 0, 12th Nov, 2012

Page 1 of 1