Part Submission Warrant


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NamePart Submission Warrant
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Part Submission Warrant rev.11011

Part Name Part Number
Safety and/or

Government Regulation  Yes  No Engineering Drawing Change Level Dated
Additional Engineering Change Dated
Shown on Drawing No. Purchase Order No. Weight kg
Checking Aid No. Engineering Change Level Dated


SUPPLIER MANUFACTURING INFORMATION

Supplier Name Supplier Code

Street Address

City/State/Postal Code

SUBMISSION INFORMATION
 Dimensional  Materials/Function  Appearance
Customer Name/Division

Buyer

Application


REASON FOR SUBMISSION

 Initial Submission

 Engineering Change(s)

 Tooling; Transfer, Replacement, Refurbishment, or additional

 Correction of Discrepancy
 Other - Please specify



 Change to Optional Construction or Material

 Sub-Supplier or Material Source Change

 Change in Part Processing

 Parts Produced at Additional Location



REQUESTED SUBMISSION LEVEL (Check one)

 Level 1 -

 Level 2 -
 Level 3 -

 Level 4 -

 Level 5 -


Warrant and Acceptance Sample Application if applicable

Warrant, Parts, Drawings, Inspection Results, Laboratory and Functional Results, Packaging Specification, Acceptance Sample Application if applicable,

At Customer Location - Warrant, Parts, Drawings, Inspection Results, Laboratory and Functional Results, Packaging Specification, Control Plan Special Characteristic List, Process Flow Diagram, FMEA, Control Plan, Process Capability Results, Gage Study, Acceptance Sample Application if applicable,

Per Level 3 but without Parts

At Supplier Location - Warrant, Parts, Drawings, Inspection Results, Laboratory and Functional Results, Packaging Specification, Control Plan Special Characteristic List, Process Flow Diagram, FMEA, Control Plan, Process Capability Results, Gage Study, Acceptance Sample Application if applicable,


SUBMISSION RESULTS

The results for  dimensional measurements  material/ functional tests  appearance criteria  statistical process package

These results meet all drawing and specification requirements;  Yes  No (If “No”, Explanation required)
DECLARATION

I hereby affirm that the samples represented by this warrant are representative of our parts, and have been made to the applicable Production Parts Approval Process Manual 3rd Edition Requirements. I further warrant these sample parts were produced at the production rate of . I have noted any deviations from this declaration below.
EXPLANATION/COMMENTS;
Print Name Title Phone No.

Fax No.
Supplier Authorized Signature Date





FOR MAZDA USE ONLY




Comments;

 Approved  Rejected  Other ___________________

Approval Number _________________ Date _________________

Engineer Signature _____________________________________

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