QUALIFICATION TEST RECORD – 9ND (6/09)

MANUFACTURER'S NAME / TEST REPORT NUMBER / TEST REPORT DATE

NAVY AUTHORIZATION LETTER: ______

(List any deviations authorized by the qualifying activity:)

SPECIFICATIONS FOR WHICH QUALIFICATION IS DESIRED:

GENERAL SPECIFICATION NUMBER / REVISION / AMENDMENT
DETAIL SPECIFICATION NUMBERS / REVISION / AMENDMENT

TYPE OF QUALIFICATION PROGRAM:

____ INITIAL QUALIFICATION ____ RETENTION OF QUALIFICATION

____ REQUALIFICATION (to revised or amended specifications)

EXTENT OF QUALIFICATION TESTING PERFORMED:

_____ COMPLETE ______PARTIAL (explain details)

NAME AND ADDRESS OF TESTING LABORATORY OR LABORATORIES:

Primary Test Site Secondary Test Site(s)

GOVERNMENT DCMC QAR CERTIFICATION:

I certify that I have reviewed the information contained in this test record form and the qualification test report, if applicable, and the data and information contained herein are complete and accurate to the best of my knowledge.

QAR SIGNATURE / TITLE / DATE
TEST REPORT NUMBER

COMPLETE AND DESIRED QPL LISTING -List all of your products by the part numbers in the format required by the applicable specification and cross-reference the specification part numbers to your part numbers. Attach additional pages if necessary. Place an asterisk in front of the part numbers tested. The specification part numbers may not be used for the manufacturer's part number.

Specification Manufacturer's Manufacturer's

Part Numbers Part Numbers Name & Address

______

Office: (Where contracts

are received)

Plant: (Primary source of

manufacturing &

control)

Commercial and Government

Entity (CAGE) Number:

TEST REPORT NUMBER

TEST SUMMARY SHEET

(This form is used only for summarizing the results of the test program)

(Provide a separate summary sheet for each sample type tested)

(Attach additional sheets as needed)

Specification Part Number(s) Tested:
TEST GROUP (if applicable) & TEST PERFORMED / REQUIREMENT PARAGRAPH / TEST METHOD PARAGRAPH / NUMBER TESTED / NUMBER FAILED / REPORT PAGE # / REMARKS
TEST REPORT NUMBER

MANUFACTURER CERTIFICATIONS

A. We certify that the information and data contained in this form and our associated test report are accurate and truthful statements concerning the products for which we desire qualification approval

B. We certify that we have tested items and/or supplied items for testing which are representative of our normal production capability.

C. We certify that we have read the provisions outlined the DoD publication SD-6 "Provisions Governing Qualification". We have abided, and will abide by, these provisions at all times while being listed on the government Qualified Products List (QPL).

D. As required by SD-6, we will notify the qualifying activity of any change in our product design, material, or manufacturing process after qualification samples have been submitted or qualification granted. We will also state in our notification to the qualifying activity whether we believe the change will prejudice the capability of the product to meet the qualification test requirements.

E. We maintain a quality assurance system at the manufacturing and test locations that conform to MIL-I-45208 including the calibration requirements of MIL-STD-45662.

F. We accept that the Naval Air Systems Command (NAVAIR) will review test reports and intellectual property related to Navy QPL programs, including information marked proprietary, sensitive, private, confidential, etc. We understand the manufacturer must maintain a copy of their test report on file for 6 years from date of qualification. The copy submitted to NAVAIR will be destroyed upon completion of the project. After NAVAIR performs the testing, the test data sheets and test summary will be destroyed when NAVAIR receives the read receipt from the manufacturer. If a written Non-Disclosure Agreement is required, please contact the QPL Point of Contact at NAVAIR.

CERTIFICATION; INCLUDE SIGNATURES OF TWO COMPANY EMPLOYEES CAPABLE OF ASSURING THE ABOVE PROVISIONS ARE MET.

MANUFACTURER'S SIGNATURES / TITLE / DATE

2