Attachment 0002 - Item Information Certification Statement Template.docx
DOCX document 159 KB Posted
- Attached to
- Special Ammunition & Weapon Systems (SAWS) Federal contract opportunity
- Solicitation number
- W15QKN22R0057
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IICS Control No:
Date of Execution:
LAT Concurrence Date:
Item Information and Certification Statement (For CONUS Block 1 and OCONUS Block 1, 2 & 3 Required) Click here to enter text.
Bill of Lading #:
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Shipment #:
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Point of Embarkation:
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Ship to Address:
Mark For:
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Signature of USG Receiving Official Date Title and Contact Number USG Receiving Official (printed/stamped) Signature of USG Receiving Official USG Receiving Official (printed/stamped) Title and Contact Number Signature of USG Representative USG Representative (printed/stamped) Title and Contact Number
DATE
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Phone Number:
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Prime Contract Number/DO#:
Contract Line Item # (CLIN):
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Item Description:
Shipment Quantity:
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Total # of Pallets:
LOT #'s:
Year of Manufacturer:
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Supplier Name/City/Country:
Tech. Data Pkg./Eng. Change Pkg. Approval Date:
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3) Acknowledgement of visual inspection, which includes kind, count, and condition of the packaging, marking, and palletization of the items on behalf of the U.S. Government:
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1) Acknowledgement of visual inspection at source on behalf of the U.S. Government:
Date
DATE
2) Acknowledgement of receipt of the items on behalf of the U.S. Government and assumption of full responsibility for movement from this point forward:
Date
DATE
SEA
(TCN): FMS Case Identifier:
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GROUND
AIR
Check Box:
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Transportation Control #
Prime Contractor Name:
File details come from the government source that posted it. Updated .