首件样品检验报告

购货商(客户)/ BUYER (Customer) 首件样品检验原因 Reas on for in itial sample in specti on _新供应商 new supplier 新零件n ew part _ 规格更改 changed specifications

_ 产品加工过程更改 changed production process _ 新的制造地 new manufacturing location 产品长期停产 >1 年 exten ded in terrupti on of product ion >1year 由供应商和客户共同核准的首件样品检验的规范，存放在以下文档中 in specti on are con tai ned in the follow ing docume nts:

第1张 共 Sheet 1 of sheet

供应商编号Supplier ID : 名称Name 填写"公司的英文或中文名及相应中文拼音" Write “company name or in Chinese pinyi 地址Address 填写"公司地址"

接收人 RecipienWrite “company adress “ -----------

部门Dept:填写“相关接收样品的部门” write a recipient department name “ 姓名Name:填写“接收样品的人员姓名” Write a recipient name “

首件样品检验报告 In itial Sample In specti on Report

外观批准报告(由品质部批准) Appeara nce Approval Report (AAR by quality)

尺寸检验报告 材料检验报告 Dime nsion Report Material Report 性能检验报告 Function Report

零件编号. Part No. 填写“图号" Write “ part 签发日期 Date issued 填写报告日期 Write report date

零件名称 Desig nati on Write “ . ” part n ame

报告编号 Report No. 填写内部报 告编号 Write report No

图纸版本 In dex: 参考 Refere nce Write last FSR No 零件编号. Part No. 签发日期 Date issued 零件名称 Desig nati on 报告编号. Report No. 模具编号填写模具编号 模腔数目填写模腔数 Tool No. write “ mould No No. of cavities write “ cavity NO 样品数量 Quan tity of samples 备注 Remark 图纸版本 In dex

参考 Refere nce

检验结果见附表 实际尺寸见样品检验单 不合格的在“ AT ”栏中注明

违禁物质声明 /Declaration of substances: 是 /yes 否/no REACH 禁用物质清单 REACH candidate list(SVHC): no SVHC substances in a concentration>0.1%, reference 参见:

___ 是 /yes | 否/no* ----- >* 签名 / Signature

For in specti on results, refer to attached sheets: The actual measureme nts are give n in order of the samples. Non-conforming specificati ons are in dicated in the colum n "AT".

备注(供应商"Remarks (Supplier): 填写： 「此样品第几次送样； 2.所附加其它报告(如材质报告)，或其它报告见哪份 FSR Write: 1. Sample delivery times; 2. Attached report name 备注 /Remarks (CEN): 1. Initial samples must be taken from 1~8 hours production with a minimum 300 consecutive parts, unless otherwise specified by CEN quality re除.非斯易安品质代表特别同意，首件样品必须 1~8小时 的量产，且规定的生产数量至少为 300件连续生产的零件。

条件 Conditions

我们供应商在此声明， 1. 所提交的样品是完全采用正常生产的原材料，按照正常批量生产的方 法生产的； 2. 样品检验准确结果如报告(偏差见附表) ， 3. 首件样品批准并不免除供应商按适用的图纸和规格交付产品的责任 We hereby certify, 1. That samples submitted are completely made with regular production resources following regular series production methods. 2. The correct inspections of the samples and their listing in this report (deviations are shown separately). 3. That a sample approval does not relieve the supplier of his responsibility to deliver material according to the applicable drawings and specifications.

1 2 3 4 5 尺寸 Dimensions 材质报告 Material analyse 性能测试 Eng.Fuction Test

RoHS REACH 放行 Release

结论 /Decision: 1=接收 approv ed;2. 一定条件下接收 approved with concession;3 拒收，交 新样品 rejected new samples required;4. 无要求 not requested;5. 处理中 in process.

重新送样 new sample needed I | 是 yes 日期 Date: .. .................................. . 部门Dept:

供应商/ SUPPLIER The specifications jointly approved by the Buyer and Supplier for the initial sample 名字/~电话号码（如有疑问以便联系） Name / Teleph one No. （in case of queries） 日期：填写日期date 责任人签名：签字sig nature Date Acco un table Sign ature

分发：品质 / 采购/ 物流/ 研发/ 工艺工程师 Distribution: QA/Purchasing/R&D/Logistic/Process Engineering

修改日期. Modification No. 进料日期 In com ing date 填表日期

Date of Issue

尺寸检验报告 Dime nsion Report 材料检验报告 Material Report 性能检验报告 Fun kti on Report 首件样品检验报告

In itial Sample In specti on Report 检验结果/ Test result 检验结论见表一 / Result report see page 1

供应冏 SUPP LIER 报告编号. Report No. 参考 Refere nce

供应商「SUPPLIER 填写“公司的英文或中文名及相应中文拼音” Write supplier n ame in En glish or in Chin ese Pinyi 购货商（客尸） BUYER （Customer） 报告编号. Report No. 参考 Refere nce

~ 张，第 > Sheet of Sheet 零件编号/名称 Part No./Desig nation 填写“图号”和“零件名称” write code and part name 零件编号/名称 Part No./Desig nation 供应商 /SUPPLIER 购货商(客户"Purchaser (Customer)~

编号 Pos. 规格要求 Dime nsions nominal 实测结果(供应商

)

Actual Results (Supplier) AT 实测结果(客户) Actual Results (Buyer) AT

结论

Decisi on A B C D

1 填写“图纸尺寸（必须包括公 差）或其它要求“ 填写“实测尺寸或其它要求的结果”

Write “ dimension require pluge tolera nee or other requireme nt ”

Write “ acutal measured dimension or other requireme nt result ”

重量 / Weight 备注(供应商"Remarks (Supplier):

-正楷填写 Plain Writ ing

………责任人签字 " Acco un table Sign ature