<p>Organisationsvorschrift WN 00 3 50016 Formular: Lieferantenselbstauskunft Geltungsbereich: Beschaffung und Lieferantenentwicklung</p><p>Ersteller: M. Kunz 22.07.2007 Bearbeiter: W. Mögerle 05.09.2013 Geprüft: C. Trudel 18.11.2013 Freigabe: D. Martiš 21.01.2014 Index: C ECM 1000208195</p><p>Supplier Self-Assessment </p><p>Company </p><p>Name: Address: Homepage: Business: Subsidiary of: Sales tax identification number DUNS-No. Company specific data</p><p>1. Partner</p><p>Department Name Phone Fax e-mail</p><p>President/ Managing Director</p><p>Quality Manager</p><p>Responsible for Environment</p><p>Engineering Director</p><p>Commercial Director Sales Contact at plant (Working hours)</p><p>Sales Manager</p><p>2. Number of employees Production Set up an Maintenance Quality Others Design Tool Shop Total</p><p>027f9199fc261e129f20cb1058b49139.doc Seite 1 von 5 3. Company´s turnover</p><p>The year before last: Last year: This year expectation</p><p>4. Customer- and industry structure </p><p>Number of customers: Number of main customers (80% turnover) Which main customers do you supply?</p><p>Mention at least the top three with their %-share of total revenue (if necessary just mention the %-share of total revenue without customers name).</p><p>Which industries do you supply?</p><p>Mention at least the top three with their %-share of total revenue.</p><p>5. Production´s programme</p><p>Available production processes:</p><p>Available materials:</p><p>Which approvals can you offer?</p><p>Available machines/equipment:</p><p>Which process steps are outsourced?</p><p>6. Production capacities</p><p>Describe your production capacities (i.e. number of machines)</p><p>7. Measuring and testing equipment</p><p>Describe your measuring and testing equipment</p><p>8. Standard terms</p><p>Delivery terms: Packaging terms: Payment terms:</p><p>027f9199fc261e129f20cb1058b49139.doc Seite 2 von 5 9. Logistics</p><p>Which logistic systems do you provide? (For example Kanban, consignment stock, etc.)</p><p>10. Certification level of Quality Management System Please mark the appropriate certificate and enclose it: </p><p>ISO 9000ff ISO/TS 16949 Other Yes No Comment</p><p>Further certifications planned? (When, by whom?) ______On which regulation are your initial samples per- formed? ______</p><p>Capability of design a process FMEA? ______Which Advance Quality Planning System is utilized?</p><p>Does the accuracy of your outgoing material checks ______allow a cancellation of your customer’s incoming ma- ______terial checks?</p><p>11. Corporate Social Responsibility </p><p>Does your company admit to internationally accept Yes No Comment social and ethical rules (SA 8000, UN Global Com- pact, ISO 26000, ILO etc.)? ______</p><p>Are you registered to a supplier portal (like Sedex)? ______</p><p>12. Environmental</p><p>Do you have an environmental management Yes No Comment system? - ISO 14001? ______- EMAS III (EG 1221/2009)? ______Are aspects of environmental protection an integ- ______rated part of your product planning? Is your company able to work with IMDS? If yes, please give your ID. ______Does your company follow environmental protection guidelines established in writing? ______Do you define environmental protection targets and document the results? ______Do you work towards the improvement of the envir- onmental protection with your suppliers and contract- ______ors?</p><p>13. Safety management</p><p>Do you have an occupational safety and health man- Yes No Comment agement system?</p><p>- certified to OHSAS 18001? ______- Internal system? ______</p><p>027f9199fc261e129f20cb1058b49139.doc Seite 3 von 5 14. Energy management system</p><p>Do you have an energy management system? Yes No Comment - certified according to ISO 50001? ______- Internal system? ______</p><p>15. Further certifications</p><p>Do you have further certificates? Do you plan further certifications?</p><p>Do you comply with customer standards? If so, which?</p><p>16. CAD - Data</p><p>What are the means you use to send your CAD-Data (except from paper)?</p><p>What are the CAD-Software and Data formats you use?</p><p>Can you convert 3D Data in 2D?</p><p>17. Insurance/ Guarantee</p><p>Do you have a product/third-party liability insurance Extended liability insurance for products and third-party including: damages?</p><p>Coverage of cost of recalls?</p><p>Amount of the current coverage for: Damages to persons: ______€ / Year</p><p>Damages to property: ______€ / Year</p><p>Financial losses: ______€ / Year</p><p>Recalls: ______€ / Year</p><p>A franchise of: ______€ for each damage is agreed on.</p><p>Are you insured against the US risk: Yes No</p><p>What is the maximum warranty period you can agree ______Months on with your clients?</p><p>If needed, Bürkert can get a bank reference of your Yes No company?</p><p>18. In which area / country are you currently selling?</p><p>Germany West-Europe South-Europe East-Europe</p><p>North America South America Australia / New Zealand</p><p>Asia China India Africa</p><p>027f9199fc261e129f20cb1058b49139.doc Seite 4 von 5 19. Which currencies can you quote/invoice?</p><p>20. Do you have company holidays / longer country-specific holidays?</p><p>Supplier</p><p>Date: Signature:</p><p>027f9199fc261e129f20cb1058b49139.doc Seite 5 von 5</p>