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PartNameCust.PartNumberShownonDrawingNumberOrig.PartNumberEngineeringChangeLevelDatedAdditionalEngineeringChangesDatedSafetyand/orGovernmentRegulationPurchaseOrderNo.CheckingAidNumberCheckingAidEng.ChangeLevelDatedORGANIZATIONMANUFACTURINGINFORMATIONCUSTOMERSUBMITTALINFORMATIONOrganizationName&Supplier/VendorCodeCustomerName/DivisionStreetAddressBuyer/BuyerCodeCityRegionPostalCodeCountryApplicationMATERIALSREPORTINGHascustomer-requiredSubstancesofConcerninformationbeenreported?SubmittedbyIMDSorothercustomerformat:ArepolymericpartsidentifiedwithappropriateISOmarkingcodes?REASONFORSUBMISSION(Checkatleastone)InitialsubmissionChangetoOptionalConstructionorMaterialEngineeringChange(s)Sub-SupplierorMaterialSourceChangeTooling:Transfer,Replacement,Refurbishment,oradditionalChangeinPartProcessingCorrectionofDiscrepancyPartsproducedatAdditionalLocationToolingInactivethan1yearOther-pleasespecifyREQUESTEDSUBMISSIONLEVEL(Checkone)Level1-Warrantonly(andfordesignatedappearanceitems,anAppearanceApprovalReport)submittedtocustomer.Level2-Warrantwithproductsamplesandlimitedsupportingdatasubmittedtocustomer.Level3-Warrantwithproductsamplesandcompletesupportingdatasubmittedtocustomer.Level4-Warrantandotherrequirementsasdefinedbycustomer.Level5-Warrantwithproductsamplesandcompletesupportingdatareviewedatorganization'smanufacturinglocation.SUBMISSIONRESULTSTheresultsforTheseresultsmeetalldesignrecordrequirements:(IfNO-ExplanationRequired)Mold/Cavity/ProductionProcessDECLARATIONEXPLANATION/COMMENTS:IseachCustomerToolproperlytaggedandnumbered?OrganizationAuthorizedSignatureDatePrintNameTitleE-mailFORCUSTOMERUSEONLY(IFAPPLICABLE)PPAPWarrantDisposition:CustomerSignatureDatePrintNameCustomerTrackingNumber(optional)PartSubmissionWarrantFaxNo.Iaffirmthatthesamplesrepresentedbythiswarrantarerepresentativeofourparts,whichweremadebyaprocessthatmeetsallProductionPartApprovalProcessManual4thEditionRequirements.Ifurtheraffirmthatthesesampleswereproducedattheproductionrateof____/____hours.Ialsocertifythatdocumentedevidenceofsuchcomplianceisonfileandavailableforyourreview.Ihavenotedanydeviationfromthisdeclarationbelow.Weight(kg)PhoneNo.YesNOdimensionalmeasurementsmaterialandfunctionaltestsappearancecriteriastatisticalprocesspackageYesNoYesNoYesNoApprovedRejectedOthern/an/aYesNon/a