CERTIFICATE OF CONFORMANCE
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NOTE: Prior to completing this certification, the Supplier shall review and comply with the attached form instructions.
A. A. Purchase Order/Contract Data
1. PO No.:
2. PO Rev No.:
3. PO Line Item:
4. Contract No.:
5. Contract Amendment No.:
B. Supplier/Source Information
7. Supplier Address (Street/City/State):
8. Source of Origin:
The suppliers shall take all necessary actions and precautions
to assure that this Certificate of Conformance(C of C) is accurate,
complete, and true, regardless of the actual source of origin.
C. Applicable Requirements
9. Code/Standard No.:
10. Specification No.:
11. Technical Drawings/Diagrams:
D. Approved Changes/Deviations/Waivers/Substitutions/Nonconformances:
E. Nonconformance(s): Unless otherwise directed in writing by the Procurement Agent, Do NOT deliver/ship
materials/items/equipment if there are any changes, deviations, substitutions, or nonconforming conditions that have
not been previously submitted and approved utilizing Form 540.33, Information/Change Request.
F. Certification Statement
(Supplier), hereby certifies that the materials/items/equipment identified in Section A above, and
all required documentation, conforms in all respects to the stated Purchase Order/Contract requirements and that all exceptions,
waivers, deviations, and/or nonconforming conditions are identified in Section D. Furthermore, information provided is accurate,
complete, and true pursuant to 10 CFR 820.11 (see definition).
Authorized Certifying Official (See Definitions/Instructions):