Receiving Volvo Company Date

      Report No.            

Supplier’s name and postal address INITIAL SAMPLE APPROVAL
      Result report

      Dimension Material Function

Volvo Part No. / Issue complete unit

           

     
Supplier code no.      Page 1 of       pages
Supplier’s e-mail address and fax number Approved to delegated initial sample or PPAP level 1 according
      to Key Elements Procedure 2

Volvo Part No. / Issue Volvo Drawing No. / Issue Criticality [1] and/or regulatory demands
            yes no
Handling according to STD 5036, 1 and Key Elements Procedure 2

Description Reason for the initial sample test

      new supplier
Purchase order No. Purchase order date new part
            engineering changes DCN No.     
Number of samples Weight (average-gram) changed manufacturing conditions
            new manufacturing place
long period of non-delivery ( more than 1 year )
Environmental declaration previous initial samples rejected
We confirm that no substances of those specified in Volvo’s black list new/modified/refurbished tooling
(STD 100-0002) grey list (STD 100-0003) have been used in this change of 2nd Tier supplier parts
component. Reported in IMDS when ordered and/or specified. other :
Communicate phase-out plan to your Volvo contact.

Name Signature
     

For test records, see pages:      

The test results are placed in the same order as the numbers of the initial samples.

Comments Remarks
           

We confirm,
1. That the submitted samples are manufactured by completely serial
production means and under serial production conditions.
Decision :
2. That the performance of the initial sample test and its documentation
Approved Interim approval Not approved
in this report have been done correctly (deviations from this are
particularly stated in this report). Deliveries Delivieries allowed * New samples
allowed * but see remarks required

3. That an approval does not relieve the supplier from the responsibility Dept. Name Phone
© AB Volvo 71316187-4

to always deliver in accordance with valid specifications                  

Name/Telephone (for enquiries)

     

           
Date Signature Date Signature
Volvo fills in shaded areas.
* For Renault Trucks and Volvo Powertrain France deliveries are only allowed after mountability and packaging approval