540.04
11/01/2006
Rev. 05
CERTIFICATE OF CONFORMANCE
Page 1 of 3
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
6. Supplier:
7. Supplier Address (Street/City/State):
8. Source of Origin:
CAUTION:
Street:
The suppliers shall take all necessary actions and precautions
City:
to assure that this Certificate of Conformance(C of C) is accurate,
State:
complete, and true, regardless of the actual source of origin.
Country:
C. Applicable Requirements
9. Code/Standard No.:
Revisions/Editions/Addendum:
10. Specification No.:
Revision/Editions:
11. Technical Drawings/Diagrams:
Revision:
12. Other:
Revisions/Editions/Addendum:
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):
Printed Name
Signature
Title
Date
See Instructions
C