Sample Part Request

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SAMPLE PART REQUEST
Supplier’s Representative to complete form prior to acceptance of part introduction
CONTACT INFORMATION
Purchasing Sponsor _____________________ Date: _______ File # ______
(Attach removable File # label to sample)
Representative Name: ___________________________
Company:
___________________________
Address:
___________________________
___________________________
Phone:
(
) _________________
Fax:
(
) _________________
Pager:
(
) _________________ e-mail address:________________________________
PART IDENTIFICATION
Manufacturer:__________________________Part Number:_______________________________________
Description:
_______________________________________________ Package/Case Style __________
Potential Alternate Source for: (Mfg’s name and part number) ____________________________________
Alternate Source Evaluation Request File No. _________
(Evaluation Request File No. to be completed by Components Engineer)
QUALITY ASSURANCE
Temperature Grade:
Commercial
Industrial
Military
Other (Specify) _________
(0-70 c)
(-40 + 85 c)
(-55 + 125c)
FIT (MTBF) Number
_______
:
AVAILABILITY
Current Lead-time: ____________
Sole Source: (One Manufacturer)
Y / N
Production Quantities Available Now?
Y / N If not available now, when? _____________
How long has this part been in production?
< 6 mo.
>6 mo.< 1 yr.
> 1<2 yr.
> 2 yr.
Anticipated End of product Life: (circle one)
< 1 yr.
>1<2 yr.
>2<3 yr.
>3<5 yr.
>5 yr.
Available through: (circle all that apply)
Factory
Distributor
Name of distributors currently authorized by the factory to sell this part:
1.
Name: ________________________________ Ph. (
) _______________________
2.
Name: ________________________________ Ph. (
) _______________________
COST INFORMATION
Quantities (Budgetary only)
100
250
500
1000
2500
LITERATURE
Data Sheet Attached:
Y / N
Application Notes Attached
Y / N
SAMPLE COUNT: ___________
(C.E. to complete sample section below and attach Part Qualification form with samples to this form)
Samples given to: __________________ Ext. _________ Date: __________ C.E. Follow up date: ___/___/____

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