Part Submission Warrant

(Part Submission Warrant, PSW)

Part Name Cust. Part Number

Shown on Drawing No. Orig. Part Number

Engineering Change Level Dated

Additional engineering Changes Dated

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

Checking Aid No. Checking Aid Engineering Change Level Dated

ORGANIZATION MANUFACTURING INFORMATION CUSTOMER SUBMITTAL INFORMATION

Supplier Name & Supplier/Vendor Code Customer Name/Division

Street Address Buyer/Buyer Code

City 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 appropriat ISO markingcodes? Yes No n/a
REASON FOR SUBMISSION (Check at least one)
Initial Submission Changes to Optional Construction or Material
Technical Modification(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

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 manufactoring location.
SUBMISSION RESULTS
The results for dimensional measurements material and functional tests appearance criteria statistical process package

These results meet all design record requirements: Yes No (If "No" - Explanation Required)
Mold / Cavity / Production Process
DECLARATION
I 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 / hours. I also certify that documented evidence of such compliance is on file and available for review.
I have noted any deviations from this declaration below.
EXPLANATION/COMMENTS: -

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

Organization Authorized Signature Dated

Print Name Phone No. FAX No.

Title E-mail

FOR CUSTOMER USE ONLY (IF APPLICABLE)

PPAP Warrant Disposition: Approved Rejected Other
Customer Signature Dated

Print Name Customer Tracking Number (optional)

March
CFG-1001 CAQDOC 024-EMP / 0221
2006