Truck Industry Part Name

Tool PO Number

Part Submission Warrant

Customer Part Number Engineering Drawing Change Level

Rev.
If applicable

Dated Dated

Additional Engineering Changes Shown on Drawing Number Checking Aid Number Purchase Order No. Engineering Change Level SUBMISSION INFORMATION
Customer Name/Division

Weight (kg) Dated

ORGANIZATION MANUFACTURING INFORMATION

Organization Name and Code

Street Address

Customer Contact

City

State

Zip

Application

Note:

Does this part contain any restricted or reportable substances? Are plastic parts identified with appropriate ISO marking codes?

Yes Yes

No No

REASON FOR SUBMISSION Initial submission Engineering Change(s) Tooling: Transfer, Replacement, Refurbishment, or Additional Correction of Discrepancy Tooling inactive > than 1 year 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. 1 (check) Level 5 - Warrant with product samples and complete supporting data reviewed at supplier's manufacturing location. DECLARATION I affirm that the samples represented by this warrant are representative of our parts and have been made to the applicable customer drawings and specifications and are made from specified materials on regular production tooling with no operations other than the regular production process. I also certify that documented evidence of such compliance is on file and available for review. EXPLANATION/COMMENTS: 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Change to Optional Construction or Material Sub-Supplier or Material Source Change Change in Part Processing Parts produced at Additional Location Other - please specify

List Molds / Cavities / Production Processes Organization Authorized Signature Print Name Title Phone No. E-Mail FOR CUSTOMER USE ONLY Rejected Comment: Date Fax No.

PPAP Warrant Disposition:

Approved Interim Approval

Customer Signature

Date

Print Name