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.
Supplier’s e-mail address and fax number
Volvo Part No. / Issue
Volvo Drawing No. / Issue
Criticality [1] and/or regulatory demands
Handling according to STD 5036, 1 and Key Elements Procedure 2
no
Reason for the initial sample test
Description
Purchase order No.
Purchase order date
Number of samples
Weight (average-gram)
Environmental declaration
We confirm that no substances of those specified in Volvo’s black list
(STD 100-0002) and the GADSL according to STD 100-0005 have
been used in this component. Reported in IMDS when ordered and/or
specified. Communicate phase-out plan to your Volvo contact.
new supplier
new part
engineering changes DCN No.
changed manufacturing conditions
new manufacturing place
long period of non-delivery ( more than 1 year )
previous initial samples rejected
new/modified/refurbished tooling
change of 2nd Tier supplier parts
other :
Signature
For test records, see pages:
The test results are placed in the same order as the numbers of the initial samples.
Comments
Remarks
We confirm,
1. That the submitted samples are manufactured by completely serial
production means and under serial production conditions.
2. That the performance of the initial sample test and its
documentation
in this report have been done correctly (deviations from this are
particularly stated in this report).
3. That an approval does not relieve the supplier from the
responsibility to always deliver in accordance with valid
specifications
© AB Volvo 71316187-5
pages
Approved to delegated initial sample or PPAP level 1
according to Key Elements Procedure 2
yes
Name
Page 1 of
Decision :
Approved
Interim approval
Not approved
Deliveries
allowed *
Delivieries allowed *
but see remarks
New samples
required
Dept.
Name
Phone
Name/Telephone (for enquiries)
Date
Signature
Date
Signature
Volvo fills in shaded areas.
* For Renault Trucks and Volvo Powertrain France deliveries are only allowed after mountability and packaging approval