Initial Sample Approval - Result Report

Receiving Volvo Company Date Report No. Supplier’s name and postal address INITIAL SAMPLE APPROVAL Result report

Dimension Material Function

Volvo Part No. / Issue complete unit

Supplier code no. Page 1 of pages

Supplier’s e-mail address and fax number Approved to delegated initial sample or PPAP level 1 according to Key Elements Procedure 2

Volvo Part No. / Issue Volvo Drawing No. / Issue Criticality [1] and/or regulatory demands yes no Description Reason for the initial sample test new supplier 2

Purchase order No. Purchase order date new part e r engineering changes DCN No. u d Number of samples Weight (average-gram) changed manufacturing conditions e c new manufacturing place o r long period of non-delivery ( more than 1 year ) P

Environmental declaration

s previous initial samples rejected t We confirm that no substances of those specified in Volvo’s black list n new/modified/refurbished tooling e (STD 100-0002) and the GADSL according to STD 100-0005 have change of 2nd Tier supplier parts m

e been used in this component. Reported in IMDS when ordered and/or l other : E

specified. Communicate phase-out plan to your Volvo contact. y e

K Name Signature

For test records, see pages: , 6 The test results are placed in the same order as the numbers of the initial samples. 3 0 5

Comments Remarks o t

g n i d r o c c a g n i l d n

a We confirm, H 1. That the submitted samples are manufactured by completely serial production means and under serial production conditions. Decision : 2. That the performance of the initial sample test and its documentation Approved Interim approval Not approved in this report have been done correctly (deviations from this are Deliveries Delivieries allowed * New samples particularly stated in this report). allowed * but see remarks required

3. That an approval does not relieve the supplier from the Dept. Name Phone responsibility to always deliver in accordance with valid specifications 5 -

7 Name/Telephone (for enquiries) 8 1 6 1 3

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