Part Submission Warrant

Part Name Cust. Part Number

Shown on Drawing No. Org. Part Number

Engineering Change Level Dated

Additional Engineering Changes Dated

Safety and/or Government Regulation Yes No Purchase Order No. Weight (kg)

Checking Aid No. Checking Aid Engineering Change Level Dated

ORGANIZATION MANUFACTURING INFORMATION CUSTOMER SUBMITTAL INFORMATION

Organization Name & Supplier/Vendor Code Customer Name/Division

Street Address Buyer/Buyer Code

City Region Postal Code Country Application

MATERIALS REPORTING
Has customer-required Substances of Concern information been reported? Yes No n/a
Submitted by IMDS or other customer format:

Are polymeric parts identified with appropriate ISO marking codes? Yes No n/a
REASON FOR SUBMISSION (Check at least one)
Initial Submission Change to Optional Construction or Material
Engineering Change(s) Supplier or Material Source Change
Tooling: Transfer, Replacement, Refurbishment, or additional Change in Part Processing
Correction of Discrepancy Parts Produced at Additional Location
Tooling Inactive > than 1 year Other - please specify below

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 organization's manufacturing location.
SUBMISSION RESULTS
The results for dimensional measurements material and functional tests appearance criteria statistical process package
These results meet all drawing and specification requirements: Yes No (If "NO" - Explanation Required)
Mold / Cavity / Production Process

DECLARATION
I hereby affirm that the samples represented by this warrant are representative of our parts which were made by a process that meets all Production Part
Approval Process Manual 4th Edition Requirements. I further affirm that these samples were produced at the production rate of / hours.
I also certify that documented evidence of such compliance is on file and available for review. I have noted any deviations from the declaration below.
EXPLANATION/COMMENTS:

Is each Customer Tool properly tagged and numbered? Yes No n/a

Organization Authorized Signature Date

Print Name Phone No. Fax No.

Title E-mail
FOR CUSTOMER USE ONLY (IF APPLICABLE)
Part Warrant Disposition: Approved Rejected Other

Customer Signature Date

Print Name Customer Tracking Number (optional)

March
2006 CFG-1001
 Part S ub mis si on W ar ran t

Par t Na me Part Number

S afety and/or
Gover nment R egu
l ati on Yes No En gi
ne eri ng D ra w i ng C hange Level D ated
A ddi ti onal Eng neeri ng
i C hanges D ated
S how n on D raw ng
i No . Purch ase Ord er N o. W ei ght ( kg )
C hecki ng A i
d No. En gi
ne eri ng C hange Level D ated

S UP PL IERM ANUFACTURIN G INF ORMA T ION S UB MIS SION INF ORM ATION

D imens i
on al Mat eri al s /Fun c ti onal Appe aranc e

Suppl i er Na me& Suppl

ier Co d e
C ustomer Name/D i vi si
o n

Part Submission Warrant

B uyer /Buye r C ode
S tre et Ad d res s

A ppl i cati on
Ci ty S tate Zi
p

Note : Doe s t h is p ar t co nt ain a ny r e st ri cte d o r r e po r tab le sub st anc es YES NO

Ar e plas tic par t s id en tif ied wit h app ro pr iat e ISO m arkin g cod es YES NO

REASON FOR S UBMIS SION

Ini t i
al Sub mssi
i o n C hange to O pt i onal Co nst ruc t i
o n or Mat eri al
Engi neer i ng Ch ange( s) S ub-Su ppl i
e r or Mater i
a lS ource C hange
Tool i ng: T rans f er, Repl ac emen
t , R efu rbi s hment or ad di
t i
o nal C hange n
i Part Pr oce ss i ng
Cor rec t i
o n of D isc r epanc y P art Prod uc ed at Addi t i
on al Loc at i
o n
Tool i ng In ac ti ve > 1 ye ar O t her - Pl eas e s pec i fy

REQUES TED S UBMIS SION LEV EL ( Ch ec k o ne )

Level 1 - War rant onl y ( and for de si gna ted a ppear a nc e i

t em s, an Appe aran c e Appr oval R epor t) s ub mi tt ed t o c us tomer .
Level 2 - War rant wi th pr oduc t sa mpl es and li
m i ted s uppor t i ng dat a s ubmi tte d to cus t omer.
Level 3 - War rant wi th pr oduct sa mpl es and c ompl
e te s upp ort i
ng data su bmt ted
i to c us tome r.
Level 4 - War rant and o ther eq
r ui rement s a s defi ned by c us tomer .
Level 5 - War rant wi th pr oduct sa mpl es and c ompl
e te s upp ort i
ng data revi ewed at s uppl i er's manuf ac tur i
n g l oca ti on.

S UB MIS SION RESUL T S

The es u
r l ts fo r di me nsi o nal measureme nts mate rial an d fu nc ti o na l te s ts a ppearance cri te ra
i s tati s ti
c a l proces s pac ka ge

These res ul
ts me e tal drawing ands pe c i fi
c ati o n requi reme nts : YES N O (If " NO" - E xpl anati on R equi red )
Mol d / C avi ty / Produ cti
o n Pro cess

DECLARAT ION
Ihereby affi rm th at thesa mples repres en ted by th i s war a n ta r
r ere pres en ta ti
v eof o urpa r
ts , h a ve be e nmad e to the appl
ic abl
e
P rodu c ti
on P ar tA pprov alP roc es s M anual 3rd Edi ti on Re qui reme n ts . I fu rth er w ar rant he s
t e sa mp les w er e
pro duc e d a tth e p rod uc ti
on rate of /8 h o u rs. Iha v e n o ted any de v iati o n s fro m th i
s de clarati o n b e l
ow.

EX PLA NA TION /COMMENTS :

Part Name Cust. Part Number

Shown on Drawing No. Org. Part Number

Engineering Change Level Dated

Additional Engineering Changes Dated

Safety and/or Government Regulation ✘ Yes No Purchase Order No. Weight (kg)

Checking Aid No. Checking Aid Engineering Change Level Dated

ORGANIZATION MANUFACTURING INFORMATION CUSTOMER SUBMITTAL INFORMATION

Organization Name & Supplier/Vendor Code Customer Name/Division

Street Address Buyer/Buyer Code

City Region Postal Code Country Application

MATERIALS REPORTING
Has customer-required Substances of Concern information been reported? Yes No n/a
Submitted by IMDS or other customer format:

Are polymeric parts identified with appropriate ISO marking codes? Yes No n/a
REASON FOR SUBMISSION (Check at least one)
Initial Submission Change to Optional Construction or Material
Engineering Change(s) Supplier or Material Source Change
Tooling: Transfer, Replacement, Refurbishment, or additional Change in Part Processing
Correction of Discrepancy Parts Produced at Additional Location
Tooling Inactive > than 1 year Other - please specify below

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 organization's manufacturing location.
SUBMISSION RESULTS
The results for dimensional measurements material and functional tests appearance criteria statistical process package
These results meet all drawing and specification requirements: Yes No (If "NO" - Explanation Required)
Mold / Cavity / Production Process

DECLARATION
I hereby affirm that the samples represented by this warrant are representative of our parts which were made by a process that meets all Production Part
Approval Process Manual 4th Edition Requirements. I further affirm that these samples were produced at the production rate of / hours.
I also certify that documented evidence of such compliance is on file and available for review. I have noted any deviations from the declaration below.
EXPLANATION/COMMENTS:

Is each Customer Tool properly tagged and numbered? Yes No n/a

Organization Authorized Signature Date

Print Name Phone No. Fax No.

Title E-mail
FOR CUSTOMER USE ONLY (IF APPLICABLE)
Part Warrant Disposition: Approved Rejected Other

Customer Signature Date

Print Name Customer Tracking Number (optional)

March
2006 CFG-1001