1-15-2005DATE:

SUPPLIER REQUEST FOR ENGINEERING APPROVAL

ELECTRICAL COMPARTMENT 23456789PART NAME: PART NUMBER:

QUALITY SYSTEMS ENGINEERINGSUPPLIER NAME AND ADDRESS

4290 FLEXER DR

SPRING HILL FL 3460742777690777SUPPLIER CODE:

SUPPLIER TO COMPLETE

USER DEFINE TEXTUSER DEFINEMISCINFROMATION

DESIGN COMPOSITION WIEGHT PROCESSINGDESCRIPTION OF CHANGE:

EFFECT OF CHANGE:YES NO

YES NO

ASSEMBLY

COMPONENTS

WILL INCORPORATION OF CHANGEAFFECT SHIPPING SCHEDULE?

YES NO

TIME REQ’D TO INCORPORATED CHANGEAFTER APPROVAL

SIGNATURE

TOOLING OR FACILITY CHANGES REQUIREDIF YES, COST EFFECT $ YES NO

PIECE COST AFFECTED YES NO

IF YES, COST EFFECT $

PRODUCT ENGINEERING TO COMPLETE

SUPPLIER REPRESENTATIVE

APPROVED* RELEASE ACTION REQ'D, NOTICE # REJECTED

BY SIGNATUREDATE DATECONCURRED BY

SIGNATURE

BLANKET APPROVAL GRANTED FOR SUBSEQUENT CHANGESWHICH ARE SAME AS DESCRIBED ABOVE

SUPPLIER CHECKLIST ATTACHED? SAMPLE OF CHANGED COMPONENT REQUIRED

YES NO YES NO YES NO

REASON FOR REJECTION OR QUALIFYING CONDITIONS OF ACCEPTANCE:

REVIEWED BY:

SQA DATE PURCHASING DATE

* THIS APPROVAL IS GRANTED UPON THE UNDERSTANDING THAT IT IS ADVISORY IN NATURE AND IN NO MANNER CHANGES THE SELLERS ORIGINALRESPONSIBILITY FOR INSURING THAT ALL CHARACTERISTICS, DESIGNATED IN THE APPLICABLE ENGINEERING SPECIFICATIONS AND/OR INHERENT IN THESAMPLES AS ORIGINALLY TESTED AND APPROVED, ARE MAINTAINED. SELLER ACCEPTS FULL RESPONSIBILITY FOR THE CHANGES OR TYPES OF CHANGESLISTED ABOVE; AND ABOVE

EMISSION CONTROLCODE NUMBER(SEE FORM74-107)

CONTROL ITEMEFFECTED

YES NO

USER DEFINE TEXT

CEGJul 92 1638 ( Previous editions may NOT be used)

145REF NO.:

User is able to delete logo andchange title per (form) record,thus making a generic form.Users company logo can bepasted per record.

4-4-2005Rev Date:3-1-2003Orig. Date:© 2000 / 2005 All Rights Reserved - QSE Tel +1 810.499.1015 1.2Rev Level: