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Part Submission Warrant

Part Name Cust. Part Number

Shown on Drawing No. Org. Part Number

Engineering Change Level Dated

Additional Engineering Changes N/A ---- Dated

Safety and/or Government Regulation Purchase Order No. Weight (gms) 166

Checking Aid No. Checking Aid Engineering Change Level Dated N/A

ORGANIZATION MANUFACTURING INFORMATION

POOJA FORGE LTD.Customer Name/Division

Unit-III, 49.8 Mathura Road, NH-2 ---Street Address Buyer/Buyer Code

Faridabad, Haryana 121102 INDIA ---

City Region Postal code Application

MATERIALS REPORTING

Has customer-required Subtances of Concern information been reported?

Submit by IMDS or other customer format:if submitted by IMDS, enter Module ID Number,Version and date transmitted IMDS No.-36558

Are polymeric parts identified with appropiate ISO marking codes?

REASON FOR SUBMISSION (Check at least ones)

Initial Submission Change to Optional Construction or Material

Engineering Change(s) Supplier or Material Source Change

Tooling: Transfer, Replacement, Refurbishment, or additional Change in Part Processing

Correction of Discrepancy Parts Produced at Additional Location

Tooling Inactive > than 1 year Other -- please specify

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.

Level 5 - Warrant with product samples and complete supporting data reviewed at organization's manufacturing location.

SUBMISSION RESULTS

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

These results meet all drawing and specification requirements: (If "NO" - Explanation Required)

Mold / Cavity / Production Process Cold Forging & Related Processes

DECLARATION

EXPLANATION/COMMENTS:

Is each Customer Tool properly tagged and numbered?

Organization Authorized Signature Date

Print Name Phone No. FAX No. +91-1275-262906

Title Manager (Q A) E-mail [email protected]

FOR CUSTOMER USE ONLY (IF APPLICABLE)

Part Warrant Disposition:

Customer Signature DateCustomer Name Customer Tracking Number(optional)

CFG-1001

---

120-B00205-69C

N/A N/A

M16 x 2.0 x 90.0, HEX BOLT AF061941

AF061941 ------

ARUN KUMAR +91-1275-262973

CUSTOMER SUBMITTAL INFORMATION

ANIXTER FASTENERS UK

I affirm that the samples represented by this warrant are representative of our parts, which were made by a process that meets all Production Part Approval Proces

Manual 4th Edition Requirements. I further affirm that these samples were produced at the production rate of 60000/10 hours. I also certify that documentedevidence of such compliance is on file and available for review. I have noted any deviations from this declaration below

22/5/2011

Organization Name & Supplier/Vendor Code

Country

Yes No

Yes No

Yes n/a

Yes No

Approved Rejected Other

No

n/a

Yes No n/a
mailto:[email protected]:[email protected]


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MATERIALS REPORTING
















SUBMISSION RESULTS




DECLARATION









CFG-1001

---

120-B0212-69C

N/A N/A

M16 x 2.0 x 70.0 , HEX BOLT AF061940

AF061940 ------

ARUN KUMAR +91-1275-262973





22/5/2011


Country

Yes No

Yes No

Yes n/a

Yes No


No

n/a

Yes No n/a


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MATERIALS REPORTING
















SUBMISSION RESULTS




DECLARATION









CFG-1001

---

120-B00204-69C

N/A N/A

M16 x 2.0 x 65.0 , HEX BOLT AF064723

AF064723 ------

ARUN KUMAR +91-8901412344





30/5/2011


Country

Yes No

Yes No

Yes n/a

Yes No


No

n/a

Yes No n/a


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MATERIALS REPORTING
















SUBMISSION RESULTS




DECLARATION









CFG-1001

---

120-B00204-69C

N/A N/A

M8 x 1.25 x12 , HEX SCREW AF000380

AF000380 ------

ARUN KUMAR +91-8901412344





19/5/2011


Country

Yes No

Yes No

Yes n/a

Yes No


No

n/a

Yes No n/a


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MATERIALS REPORTING
















SUBMISSION RESULTS




DECLARATION





Title Manager (Q.A) E-mail [email protected]




CFG-1001

ARUN KUMAR +91-1275-262973



I affirm that the samples represented by this warrant are representative of our parts, which were made by a process that meets all Production Part Approval ProcesManual 4th Edition Requirements. I further affirm that these samples were produced at th

8/5/2011


Country

N/A N/A

M8 x 1.25 x 25 , FLANGE SCREW C-3093730

C-3093730 ---------

120-B00266-32E

Yes No

Yes No

Yes n/a

Yes No


No

n/a

Yes No n/a


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Engineering Change Level Dated 30-06-2012

Additional Engineering Changes N/A ---- Dated ---

Safety and/or Government Regulation Purchase Order No. Weight (Kg.) 0.1500 Kg.



ARC Machine Tools (P) Ltd./IPMOA029Customer Name/Division

16/5 Karkhana Bagh, Mathura Road, Faridabad.Street Address Buyer/Buyer Code

Faridabad NCR India Suzuki Diesel / Fiat Diesel


MATERIALS REPORTING


Submit by IMDS or other customer format: PRD-F-12

if submitted by IMDS, enter Module ID Number,Version and date transmitted IMDS No.-36558










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.



SUBMISSION RESULTS



Mold / Cavity / Production Process CNC Turning & Related Processes

DECLARATION




Print Name Phone No. FAX No. 0129-4044364

Title Director ( Techinical ) E-mail [email protected], [email protected]



Customer Signature Date

Customer Name Customer Tracking Number(optional)

Mr. Prem Kumar 0129-2296070


M/S Shriram Piston & Rings Ltd./GZB.

I affirm that the samples represented by this warrant are representative of our parts, which were made by a process that meets all Production Part Approval Process

Manual 4th Edition Requirements. I further affirm that these samples were produced at the production rate of 290 Pcs./ 8 hours. I also certify that documented

evidence of such compliance is on file and available for review. I have noted any deviations from this declaration below

25.09.2013


Country

121001

Rajiv Kumar

QMD-F-04 N/A

Pin Blank G-02-860

G-02-860 AMT/SRP/G-02-860006

3900086747

Yes No

Yes No

Yes n/a

Yes No


No

n/a

Yes No n/a

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