Sender

Cover Sheet

Initial Sample Inspection Report

DwSpA

PT. NITTO ALAM INDONESIA Jl.Manis II, Kawasan Industri Manis, Tangerang, Banten 15810, INDONESIA.
Phone:(021) 5918691-93, 591968486 Fax.: (021) 5918694 Addressee

Production process & product release report Submission level: Initial sample New component Product modification ( specification modification) Production relocation Modification in production process Production suspension longer than 12 months Tool modification / correction Modification in purchased parts Change of suppliers Others Resampling New sampling Reports other samples Enclosures / Inspected
13 Process-FMEA 14 Process flow chart 15 Production control plan 16 Process capability verification 17 Test equipment list 18 Inspection device capability verification

01 Dimension check 02 Function check 03 Material tests 04 Haptic test 05 Acoustics test 06 Odor test

07 Appearance test 08 Surface test 09 EMC-test 10 Reliability test 11 Design-FMEA 12 Construction release

19 EU-Safety data sheet 20 Material data sheet/IMDS 21 Means of transport/packaging 22 Certificates 23 Process acceptance 24 Others

Supplier / Production location:

Cust.No. / DUNS-Code: Report no. / Index: Name: Part number: Drawing number: Status / Date: Delivery note no. / date: Delivery quantity: Batch number: Sample weight:

Customer
ID number: Report no. / Index: Name: Part number: Drawing number: Status / Date: Goods receipt no. / date: Order no. / date: Unloading site:
To be completed by customer

/ pieces

To be completed by customer

Supplier confirmation:
We confirm that the sample inspections were performed in accordance with VDA Volume 2, Chapter 4.

The IMDS data report was created under IMDS-ID-No.: ___________________________ Name: Comments: Department: Phone / Fax / E-Mail: Date: Customer decision
Approved Approved with conditions, resampling required Rejected, resampling required

Signature: Total
01

Single releases
02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Deviation approval no.: For returns, delivery note no. / date: Name: Department: Phone / Fax / E-Mail: Date:

Valid until: /

Quantity

Resampling due date

Comments: Signature: Status: Date:

Contents of the report

Page 1 of 4

Sheet: of Supplier / Production location: ID No. / DUNS-Code Report no. / Index: Name: Part number: Drawing number: Status / Date: Enclosure 01 Dimension test 02 Function test 03 Materials test 04 Haptic test 05 Acoustics test 06 Odor test 07 Appearance test 08 Surface test 09 EMC-test 10 Reliability test 11 Design-FMEA 12 Construction release 13 Process-FMEA 14 Process flow chart 15 Production control plan 16 Process capability verification 17 Test equipment list 18 Inspection device capability verification 19 EU Safety data sheet 20 Material data sheet 21 Means of transport / packaging 22 Certificates 23 Process acceptance 24 Others Comments of supplier / Status / Date: Customer: ID number: Report no. / Index: Name: Part number: Drawing number: Status / Date: / To be completed by customer

Type, extent and description of the enclosures

Name: Department: Phone: Fax: E-Mail: Date:

Signature:

Page 2 of 4

Product-related test results

01 Dimension test 02 Function test 03 Materials test 04 Haptic test 05 Acoustics test Supplier / Production location: ID No. / DUNS-Code: Report no. / Index: Name: Part number: Drawing number: Status / Date: Ref. No. Requirements / specifications / Supplier actual values

Status 06 Odor test 07 Appearance test 08 Surface test 09 EMC test 10 Reliability test Customer: ID number: Report no. / Index: Name: Part number: Drawing number: Status / Date: Specification met? Yes No Comments Decision customer: Approved: Rejected, resampling required Comments:

Date: Sheet: of

/ To be completed by customer

Confirmation supplier: Comments:

Name: Department: Phone: Fax: E-Mail: Date

Name: Department: Phone: Fax: E-Mail:

Signature

Date

Signature

Page 3 of 4

Process-related and other documents

11 Design-FMEA 12 Construction release 13 Process-FMEA 14 Process flow chart 15 Production control plan 16 Process capability verification 17 Test equipment list

Status

Date: Sheet: of

18 Inspection device capability verification 19 EU Safety data sheet 20 Materials data sheet 21 Means of transport / packaging 22 Certificates 23 Process acceptance 24 Others

Supplier / Production location: ID no. / DUNS-Code: Report no. / Index: Designation: Part number: Drawing number: Status / Date:

Customer: ID number: Report no. / Index: Designation: Part number: Drawing number: Status / Date:

/ To be completed by customer

Confirmation of supplier: Comments:

Decision of customer: Approved Rejected, resampling required Comments:

Name: Department: Phone: Fax: E-Mail:

Name: Department: Phone: Fax: E-Mail:

Date Signature

Date Signature

Page 4 of 4