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Part Submission Warrant

Part Name Safety and/or Government Regulation Yes No Engineering Drawing Change Level Part Number Dated Dated Purchase Order No. Engineering Change Level SUBMISSION INFORMATION Weight (kg) Dated

Additional Engineering Changes Shown on Drawing No. Checking Aid No. SUPPLIER MANUFACTURING INFORMATION

Supplier Name & Supplier Code




Customer Name/Division Street Address

City Note:

Does this part contain any restrictive or reportable substances. Are plastic parts identified with appropriate ISO marking codes

REASON FOR SUBMISSION 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

re wa s ft u So ss. & e s Pr rm sX Fo tat AP .S PP ww w
Buyer/Buyer Code Application State Zip Yes Yes Change in Part Processing Other - please specify Parts Produced at Additional Location dimensional measurements material and functional tests Yes No appearance criteria (If "NO" - Explanation Required) Title Phone No. FAX No. Date FOR CUSTOMER USE ONLY (IF APPLICABLE)

No No

Change to Optional Construction or Material

Sub-Supplier or Material Source Change

statistical process package

These results meet all drawing and specification requirements: Mold / Cavity / Production Process

DECLARATION I hereby affirm that the samples represented by this warrant are representative of our parts, have been made to the applicable Production Part Approval Process Manual 3rd Edition Requirements. I further warrant these samples were / 8 hours. I have noted any deviations from this declaration below. produced at the production rate of EXPLANATION/COMMENTS: Print Name Supplier Authorized Signature

Part Warrant Disposition:

Approved Other


Part Functional Approval:

Approved Waived

Customer Name

Customer Signature
The original copy of this document shall remain at the suppliers location while the part is active (see Glossary).

Optional: customer tracking number: #