5016Q315 ATTACH 1 to EX A 1 IN X 85 FT LG HOSE ASS 967 TC.pdf
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- Solicitation number
- N390405016Q315
About this file
This is a Certificate of Compliance template (DD Form 1423 Attachment 1 to Exhibit A) that vendors must complete and submit with each shipment of material under a contract. The form requires vendors to certify that all items furnished comply with contract requirements and includes fields for material identification details such as contract number, order number, item number, NSN/LSN, manufacturer's part number, serial number, drawing/piece number, and lot/heat numbers. The vendor's Quality Assurance Official must sign and date the certification, attesting that all inspection and test reports represent the actual attributes of items furnished and indicate full compliance with contract requirements. The template includes both a simplified certification statement option and a detailed form with comprehensive material traceability information.
The completion of this form will be required in support of solicitation N390405016Q315 for reinforced rubber hose assemblies being procured by Portsmouth Naval Shipyard. This compliance certification requirement helps ensure quality control and material traceability for delivered products.
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Text version
CONTRACT __________________
PRINTED 22 JANUARY 2025 PAGE _______
ATTACHMENT 1 TO EXHIBIT A (DD FORM 1423)
CONTRACT/SOLICITATION________________________________________________________________
ITEM ___________________________________________ (DATE FOR ITEM) __________________
REQUIRED CERTIFICATION
A. CERTIFICATION SHALL BE SUPPLIED WITH EACH SHIPMENT OF MATERIAL. CERTIFICATION
(CERTIFICATE OF COMPLIANCE) SHALL BE SUPPLIED AS OUTLINED IN PARAGRAPH B. THE VENDOR IS LIABLE FOR CONDUCTING ALL TESTS, ANALYSES, INSPECTIONS, AND EXAMINATIONS, ETC., AS SPECIFIED
BY THE CONTRACT AND SPECIFICATIONS WHETHER CERTIFICATIONS ARE REQUIRED OR NOT.
CERTIFICATE OF COMPLIANCE (PROVIDE THE FOLLOWING VERBATIM STATEMENT OR COMPLETE THE
OPTIONAL FORM AT THE END OF THIS PART)
"I ATTEST ALL ITEMS FURNISHED ON THIS CONTRACT ARE IN FULL COMPLIANCE WITH ALL CONTRACT
REQUIREMENTS".
B. CERTIFICATION SHALL BE SUPPLIED PER THE FOLLOWING INSTRUCTIONS:
1. THE CERTIFICATION OF COMPLIANCE SHALL CONTAIN THE SIGNATURE AND TITLE OF THE
VENDOR OFFICIAL DESIGNATED RESPONSIBLE FOR QUALITY ASSURANCE.
2. THE MATERIAL IDENTIFICATION (E.G. LOT, BATCH, PART #, ETC.) SHALL BE INCLUDED ON THE
CERTIFICATE OF COMPLIANCE.
CERTIFICATE OF COMPLIANCE
COMPANY NAME
MATERIL IDENTIFICATION (COMPLETE APPLICABLE ITEMS)
CONTRACT __________________
PRINTED 22 JANUARY 2025 PAGE _______
ATTACHMENT 1 TO EXHIBIT A (DD FORM 1423)
CONTRACT NO. ______________ ORDER NO. ________________ ITEM NO.
NATIONAL/LOCAL STOCK NO. NSN/LSN ____________________________________________________
MANUFACTURER’S PART NO. _____________________________________________________________
MANUFACTURER’S SERIAL NO. ___________________________________________________________
DRAWING AND PIECE NO.
MANUFACTURER’S LOT/HEAT NOS. AS MARKED ON THE MATERIAL _________________________
ALL INSPECTIONS AND TEST REPORTS REQUIRED BY ATTACHMENT I TO EXHIBIT A (DD FORM 1423) FOR
TRACEABILITY TO EACH CONTRACT ITEM MUST ACCOMPANY THIS SIGNED STATEMENT:
THE INSPECTION AND TEST REPORTS (AS APPLICABLE) PROVIDED REPRESENT THE ACTUAL ATTRIBUTES OF THE ITEMS FURNISHED ON THIS CONTRACT AND INDICATE FULL COMPLIANCE WITH ALL CONTRACT REQUIREMENTS. I ATTEST ALL ITEMS FURNISHED ON THIS CONTRACT ARE IN FULL COMPLIANCE WITH
ALL CONTRACT REQUIREMENTS.
SIGNATURE ___________________________________________________ DATE
QUALITY ASSURANCE OFFICIAL
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