Certificate of Conformance Form

A. Purchase Order/Contract Data

B. Supplier/Source Information

C. Applicable Requirements

D. Approved Changes/Deviations/Waivers/Substitutions/Nonconformances:

E. Nonconformance(s): Unless otherwise directed in writing by the Procurement Specialist, Do NOT deliver/ship materials/items/equipment if there are any changes, deviations, substitutions and/or nonconforming conditions that have not been previously submitted and approved.

F. Certification Statement

I, , hereby certifies that the materials/items/equipment identified in Section A above, and all required documentation, conforms in all respects to the stated Purchase Order/Contract requirements and that all exceptions, waivers, deviations, substitutions and/or nonconforming conditions are identified in Section D. Furthermore, information provided is accurate, complete, and true pursuant to 10 CFR 820.11 (see definition).

Authorized Certifying Official (See Definitions/Instructions):

Instructions

Prepare a Certificate of Conformance (C of C) addressing each Purchase Order line item, Contract Deliverable, and/or each partial shipment. Unless otherwise specified, the C of C shall accompany each shipment. All applicable form entries must be completed.

A Supplier system-generated C of C may be attached and referenced. All applicable information required on this form shall be accounted for. Section C through Section D shall be completed in their entirety, regardless of any attachments used.

Definitions

Authorized Certifying Official. The certification shall be attested to by an authorized representative of the supplier; and the certification system, including the procedures for completing, reviewing, and approving the certificate shall be described in the Company's administrative control system or Quality Assurance program.

Certification. The act of determining, verifying, and attesting in writing to the qualifications of personnel, processed procedures, or items in accordance with specified requirements.

Certificate of Conformance. A document signed or otherwise authenticated by an authorized individual certifying the degree to which items or services meet specified requirements.

Section A, Purchase Order (PO)/Contract Data

Entry 1 Enter the complete BWXT Pantex Purchase Order (PO) or Contract Number.

Entry 2 Enter PO/Contract Revision or Amendment Number (if applicable).

Entry 3 Enter as applicable, the PO Line Item Number (i.e., 1, 2, 3), quantity, heat/cast number, lot/batch number, serial number, and item identification.

Section B, Supplier/Source Information

Entry 4 Enter the legal Supplier company name, as stated on the PO or Contract.

Entry 5 Enter the Supplier business address, as stated on the PO or Contract.

Section C, Applicable Requirements

Entry 6 Enter the applicable design code/standard number and applicable revision, issue, edition, or addendum.

Entry 7 Enter the applicable specification number and applicable revision, issue, edition, or addendum.

Entry 8 Enter the applicable technical drawing/diagram and applicable revision, issue, edition, or addendum.

Entry 9 Mark the applicable box manufacturer published description/product description or manufacturers specification.

Entry 10 Enter other applicable requirements documents and applicable revision, issue, edition, or addendum.

Section D, Approved Changes/Deviations/Waivers/Substitutions/Nonconformances

Enter any approved changes. Reference change documentation control numbers as applicable. (Attach additional pages if necessary).

Section E, Nonconformance(s)

Self-Explanatory.

Section F, Certification Statement (see definitions)

Enter the Company name (or commonly used acronym).

Print or type the authorized company certifying officials name, title, and date.

Sign or otherwise authenticate by company certifying official.

Transmittal:

BWXT Pantex, LLC
Fax: 806-477-3891
Attn: SUPPLIER QUALITY

Or e-mail with a PDF file. supplierquality@pantex.com

Place a copy with the shipment.