CERTIFICATE OF COMPLIANCE.docx
DOCX document 21 KB Posted
- Attached to
- Demineralizer
- Solicitation number
- N4215826QE025
About this file
This is a Certificate of Compliance form required by the Naval Sea Systems Command (NAVSEA) for Solicitation N4215826QE025 related to a Demineralizer procurement. The certificate serves as a contractor attestation that supplied materials fully comply with all contract requirements, including specifications, drawings, preservation, packaging, marking, and physical item identification. Contractors must provide two copies of the certificate—one accompanying the shipment in the packing list envelope and one mailed separately to arrive upon receipt of materials, both marked for attention to Code 00Q at Norfolk Naval Shipyard.
The certificate requires completion of material identification fields including contract number, order number, item number, National Stock Number or Local Stock Number, manufacturer's part number, serial number, drawing and piece number, and manufacturer's lot or heat numbers. The form must be signed by a legally authorized company representative and include certification language acknowledging that false or fraudulent statements may result in prosecution under Title 18, United States Code, Section 1001. A Quality Assurance Official signature is also required, along with confirmation that inspection and test reports represent actual attributes of items furnished and indicate full compliance with all contract requirements. Failure to provide certification at the time of shipment may result in material rejection and return at the contractor's expense. Completed certificates should be mailed to Norfolk Naval Shipyard, Code 2305.6, Expediting Section, Building 297, Portsmouth, VA 23709-5000.
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Text version
E-246-W002 CERTIFICATE OF COMPLIANCE (NAVSEA) (OCT 2018)
(a) A certification of material shall be provided by the Contractor, one (1) copy to accompany the shipment (in the packing list envelope) and (l) copy mailed to arrive at time of receipt of the shipment. Mark all certificates to the attention of Code 00Q.
(b) The certificate shall state compliance of material with drawing specification and contract/order requirements. The certificate shall as a minimum state the company name, contract/order number, drawing or specification number, and date. The certificate shall state, above the signature of a legally authorized representative of the company, the following:
This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under Title 18, United States Code, Section 1001.
(c) Failure to provide certification at the time of shipment may result in material being rejected and returned at the contractor's expense.
(d) The certificate shall read as follows:
I certify that on ______ [insert date], the ____ [insert Contractor’s name] furnished the supplies called for by the Order/Contract No._____ via ____ [Carrier] on ________ [identify the bill of lading or shipping document] in accordance with all applicable requirements. I further certify that the supplies or services are of the quality specified and conform in all respects with the contract requirements, including specifications, drawings, preservation, packaging, packing, marking requirements, and physical item identification (part number), and are in the quantity shown on this document.
Date of Execution: ________________________________ Signature: _______________________________________ Typed Name: ____________________________________ Title: ___________________________________________
CERTIFICATE OF COMPLIANCE
SOLICITATION # N4215826QE025
COMPANY NAME
MATERIAL IDENTIFICATION (COMPLETE APPLICABLE ITEMS)
CONTRACT NO. ____________________ ORDER NO ___________
ITEM NO. _______________________
NATIONAL/LOCAL STOCK NUMBER NSN/LSN ________________________
MANUFACTURER’S PART NO. ____________________________
MANUFACTURER’S SERIAL NO. __________________________
DRAWING AND PIECE NO. ______________________________
MANUFACTURER’S LOT/HEAT NOS. AS MARKED ON THE MATERIAL:
I ATTEST ALL ITEMS FURNISHED ON THIS CONTRACT ARE IN FULL COMPLIANCE WITH ALL CONTRACT REQUIREMENTS.
SIGNATURE _________________________________ DATE _______
QUALITY ASSURANCE OFFICIAL
TITLE _________________________________
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.
| REQ’D | N/A |
| [ ] | [ X ] |
SIGNATURE _________________________________ DATE _________
QUALITY ASSURANCE OFFICIAL
TITLE ________________________________
“NOTE”: WHEN ITEM(S) HAVE BEEN SHIPPED, PLEASE COMPLETE CERTIFICATION(S) AND RETURN. THIS WILL EXPEDITE RECEIPT AND PAYMENT.
MAIL TO:
NORFOLK NAVAL SHIPYARD
ATTN: CODE 2305.6, EXPEDITING SECTION
BLDG. 297
PORTSMOUTH, VA 23709-5000
DELIVER ONE (1) COPY WITH MATERIAL
ENCLOSURE (1)
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