Receiving Volvo Company                                                                                                                       Date
                                                                                                         Report No.                                                        
                    Supplier’s name and postal address                                                   INITIAL SAMPLE APPROVAL
                                                                                                         Result report
                                                                                                                Dimension                    Material                    Function
                                                                                                         Volvo Part No. / Issue  complete unit
                                                                                                                  
                                                                                                         Supplier code no.                              Page 1 of               pages
                    Supplier’s e-mail address and fax number                                                      Approved to delegated initial sample or PPAP level 1 according
                                                                                                                  to Key Elements Procedure 2
                    Volvo Part No. / Issue                       Volvo Drawing No. / Issue               Criticality [1] and/or regulatory demands
                                                                                                              yes           no
                    Description                                                                          Reason for the initial sample test
             2               
                                                                                                              new supplier
             e
             r      Purchase order No.                           Purchase order date                          new part
             u
             d                                                                                                engineering changes DCN No.     
             e
             c      Number of samples                            Weight (average-gram)                        changed manufacturing conditions
             o
             r                                                                                                new manufacturing place
             P                                                            
                                                                                                              long period of non-delivery ( more than 1 year ) 
             s
             t      Environmental declaration                                                                 previous initial samples rejected
             n
             e      We confirm that no substances of those specified in Volvo’s black list                    new/modified/refurbished tooling
             m      (STD 100-0002) and the GADSL according to STD 100-0005 have been                          change of 2nd Tier supplier parts
             e
             l
             E      used in this component. Reported in IMDS when ordered and/or                              other : 
              
             y      specified. Communicate phase-out plan to your Volvo contact. 
             e
             K
                    Name                                        Signature
             d
             n               
             a
                             
             1
                    For test records, see pages:           
             ,
             6      The test results are placed in the same order as the numbers of the initial samples. 
             3
             0
             5
              
             D
             T
             S      Comments                                                                             Remarks
              
             o                                                                                                    
             t
              
             g
             n
             i
             d
             r
             o
             c
             c
             a
              
             g
             n
             i
             l
             d      We confirm,
             n
             a      1. That the submitted samples are manufactured by completely serial 
             H
                      production means and under serial production conditions.                           Decision : 
                    2. That the performance of the initial sample test and its documentation                 Approved                Interim approval              Not approved
                      in this report have been done correctly (deviations from this are                  Deliveries             Delivieries allowed *          New samples 
                      particularly stated in this report).
                                                                                                         allowed *              but see remarks                required
                    3. That an approval does not relieve the supplier from the responsibility            Dept.                  Name                           Phone
                      to always deliver in accordance with valid specifications                                                                                         
                5     Name/Telephone (for enquiries)
                -
                7
                8
                1              
                6
                1
                3
                1
                7
                 
                o
                v
                l
                o                                                                                                 
                V
                 
                B
                A      Date                                   Signature                                  Date                                      Signature
                 
                ©
                    Volvo fills in shaded areas. 
                    * For Renault Trucks and Volvo Powertrain France deliveries are only allowed after mountability and packaging approval