P/N________________________ |
PO/Contract No.____________________ |
PO/Contract Qty _______ |
| QTY SCRAPPED & DISPOSED OF ____________________ |
PCS/ITEM No. ____________________ |
FROM (33-68) CONTRACT ITEMS SPECIFICATION AND SCHEDULE
| VIR No. |
AND/OR (SELLER/DAC) REJECTION TAG No. |
DISPOSAL METHOD (CHECK APPROPRIATE BLOCK[S])
|
PART(S) OR MATERIAL(S) MUTILATED TO SUCH AN EXTENT THAT IT COULD NOT POSSIBLY BE USED FOR IT'S ORIGINALLY INTENDED PURPOSE. |
| |
PART(S) OR MATERIAL(S) CUT IN TWO (2) OR MORE SEGMENTS. |
| |
OTHER METHOD THAT EFFECTIVELY DESTROYS THE PART(S) OR MATERIAL(S). |
|
BRIEF DESCRIPTION OF OTHER METHOD _______________________
__________________________________________________________
__________________________________________________________ |
I, THE UNDERSIGNED, AN OFFICER OF THE COMPANY DO HEREBY CERTIFY THAT PART(S) OR MATERIAL(S) NOTED ABOVE WERE SCRAPPED AND DISPOSED OF IN THE MANNER INDICATED. (REJECTION DOCUMENTATION ATTACHED.)
|
SIGNATURE ______________________________________________
|
|
NAME (TYPED) ___________________________________________
|
|
TITLE ___________________________________________________
_________________________________________________________
|
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DATE ___________________________________________________ |
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