994 Antelope Road
White City, OR 97503
Phone 541-826-2405
Fax
541-826-1205
SUPPLIER SURVEY
Company Information
Company Name _________________________________________________
Primary Contact _________________________________________________
Address
_________________________________________________
_________________________________________________
Telephone
____________________ Fax
____________________
Email Address _________________________________________________
Type of business
___ Manufacturer Rep
___ Manufacturer
___ Assembly Plant
___ Distributor
___ Service Provider
___ Fabrication Plant
Other ________________________
Organization
Management
__________________________
Name
__________________________
Name
__________________________
Name
Total Employment
_____________
Annual Sales
_____________
Years in business
_____________
____________________
Title
____________________
Title
____________________
Title
Facilities Information
Number of facilities ______
Other Locations _________________________
Is the facility registered or licensed by any Federal, State or professional agency?
Yes ______
No ______
If yes, please list _______________________________________________________
Is the product manufactured or processed at this location?
Yes ______
No ______
If sub-contractors are used in producing your product please list below.
______________________________________________
______________________________________________
Accounting
Terms (check one)
____ Net 30
____2% Net 10 ____1%Net 10
____Other
If other is checked – please provide information ____________________________________
Preferred Method of Payment (check one)
____Check
____Wire Transfer
_____Other
If other is checked – please provide information ____________________________________
F-210 Rev G 7/26/13
Page 1 of 3
Quality System
Is your Quality System based on the ISO 9001:2008 Standard?
Yes ___
No ___
Yes ___
No ___
If yes, please return a copy of the certificate with this form
Certification Expiration Date _______________________
Is your company AS9100 certified?
If yes, please return a copy of the certificate with this form
Certification Expiration Date _______________________
Other certifications or standards: __________________________________
Head of Quality __________________________
Name
____________________
Title
Are your Quality Procedures in written format?
Yes ___
No ___
If yes, please return a copy of your Quality Manual Index with this form
Who is responsible for document control?
______________________ ___________________
Name
Title
Do you maintain a controlled list of approved vendors and subcontractors?
Yes ___ No ___
Do you maintain a Calibration Schedule for test and inspection equipment?
Yes ___ No ___
Is Work-In-Process Inspection part of your Manufacturing Process?
Yes ___ No __
Do you maintain history files of inspection results?
Yes ___ No ___
Do you have a Non-conforming Product Control Program in place?
Yes ___ No ___
Do you have a Corrective Action Program in place?
Yes ___ No ___
Are Statistical Process Controls utilized?
Yes ___ No ___
Survey response prepared by ___________________________ ____________________________
Name
Title
Comments _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Please return form and additional documents to:
Purchasing Department
Ascentron, Inc.
Fax: 541-826-1205
**************************************************************************************
F-210 Rev G 7/26/13
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For internal use only
Customer-specified supplier
Supplier of inventory material
Supplier of non-inventory material
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Reviewed by _______________________________________Materials Manager
F-210 Rev G 7/26/13
Date _____________
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