The Sourcing Co.
P.O. Box [Box Number]
[City, State, ZIP Code]
CERTIFICATE OF CONFORMANCE
Index No.: [Index Number]
Page No.: 1 of [Total Pages]
Issue No.: [Issue Number]
NOTE: Prior to completing this certificate, the Supplier shall review and comply with the attached form instructions.
A. Purchase Order/Contract Data
PO/Contract No.:
Revision/Amendment No.:
PO Line Item Information: Line Item Number _______ Quantity _______
Heat/Cast Number _______ Lot/Batch Number _______ Serial Number _______
Item Identification _______
B. Supplier/Source Information
4. Supplier:
Supplier Address (Street/City/State):
C. Applicable Requirements
6. Code/Standard No.: _______ Revision/Issue/Edition/Addendum: _______
Specification No.: _______ Revision/Issue/Edition/Addendum: _______
Technical Drawings/Diagrams: _______ Revision/Issue/Edition/Addendum: _______
Manufacturer Published Description/Product Description: _______ Manufacturer Specification: _______
Other: _______ Revision/Issue/Edition/Addendum: _______
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
[The Sourcing Co.], hereby certifies that the materials/items/equipment identified in Section A above, and all required documentations, conforms to the stated Purchase Order/Contract requirements and that all exceptions, waivers, deviations, substitutions and/or nonconforming all respects are identified in Section D. Furthermore, information provided is accurate, complete, and true pursuant to [Relevant Regulation] (see definition).
Authorized Certifying Official (See Definitions/Instructions):
Printed Name: _________________________
Signature: _________________________
Title: _________________________
Date: _________________________
Contact Information
[Company Name]
[Address]
[Phone]
[Fax]
Email: [Email]
Website: [Website URL]
Transmittal
Please ensure all sections are completed accurately. Place a copy with the shipment