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

Suppl i er Na me &Suppl
ier Co d e
C usto me r N ame/D i vi si on

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

A ppl i cat on
i
Ci ty S ta te Zi p

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

T he re s ul
ts fo r di me nsional meas ure men ts m a terialand fu nc ti o nalt es ts appe a ranc e c rte r
i ia s tati s ti
c a l proc es s pa ck a ge

T he se resu l ts m eet al drawingands pe ci fi ca ti o n requi reme n ts: 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 hereby a ffi rm th a tt he sa mplesrepr es ente d b y th i s warrant are repres en ta ti
v eo fo u r parts , h av e be e nmad e to th e a p plica bl
e
P rodu c ti o n P a rt Ap p r
o valP roce s s M a nua l 3rd Edi ti o n Re q uire men ts . I fu rth er warrant th es e s a mples were
pro duce da t the pr odu c ti
on rate o f /8 ho urs .I ha v e n o te d a ny de vi a ti
o ns fro m th i
s dec l
ara ti o n b elow.

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