Specific Requirements

(for use with ISO/TS 16949:2009 Third Edition)

PART SUBMISSION WARRANT

Part Name Part Number :

Safety and or Government Yes No Regulation Any authorized Engineering Change Documents

Engineering Drawing Change Level

Dated: Dated: Weight (Kg) Dated:

Shown on drawing no. Checking Aid No.

Purchase Order no. Engineering Change Level: SUBMISSION INFORMATION

SUPPLIER MANUFACTURING INFORMATION Supplier Name & Supplier Code :

Dimensional

Material

Performance Appearance

Street Address : City State Pin code

Customer Name / Division Buyer / Buyer code___________________________ Application

Note: Does this part contain any restricted or reportable substance. Are plastic parts identified with appropriate ISO marking codes. REASON FOR SUBMISSION Initial Submission / production Engineering Change(s) Tooling Transfer, Replacement, Refurbishment or additional Correction of Discrepancy Tooling Inactive > than 1 year. REQUESTED SUBMISSION LEVEL ( Tick one ) Level 1 Level 2

Yes Yes

No No

Change to Optional Construction or Material Sub supplier or Material Source change Change in Part Processing Parts Produced at Additional Location Other Please rectify

- Warrant only (and for designated appearance items, an Appearance Approval Report) - Warrant with appearance approval report, product samples, design records, change documents (if any), dimensional results, and test results. - Warrant with appearance approval report, product samples, design records, change documents (if any), dimensional results, test results, process flow diagrams, process FMEA, control plan, Process Capability study, gauge study, Design Engg Approval, Drawing. - Warrant as per level 3, without product samples. - At supplier location, per level 3.

Level 3 Level 4 Level 5

SUBMISSION RESULTS : The results for Dimensional Material These results meet all Drawing and Specification Requirements DECLARATION

Performance Appearance Statistical Yes No ( If No Explanation Reqd )

I hereby affirm that the samples represented by this warant 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 produced at the production rate of ______/ 8 hrs. I have noted any deviations from this declaration below. EXPLANATION / COMMENTS Supplier Authorised Signature :
Date

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Specific Requirements
(for use with ISO/TS 16949:2009 Third Edition)

PART SUBMISSION WARRANT

INSPECTION RESULTS: PPS NO: / supplier process details 1.3 Control Plan no. IPS No. Process FMEA No. SPC study results : Cpk = ______________ Date : Date : Date :

Manager Strategic Sourcing Date : FOR CUSTOMER COMMITTEE APPROVAL

Part Warrant Disposition

Approval No. Manager Unit QC

Approved
Unit MR :

Rejected
Approval Date

Others
Customer Representative :

CQE Incharge :

Date:

Date:

Date:

Date:

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