Supplier Product/Process Change Notice

Rev B
PCN Information
Supplier Name PCN #
Supplier Location(s) Request Date
Contact Name Implement Date
Phone # Product
Email Identification

Category of Change
1. Product Design 2. Assembly / Fabrication Process
3. New Tooling / Mold 4. Manufacturing Site / Location
5. Sub Supplier or material source 6. Material type or component
7. New equipment 8. Changes on critical equipment parameters
9. Others

Description of Change & Reasons

Important Dates
Qualification Samples avaliable Old product final shipment date
Final Qualification data avaliable Last Time order date

Method of Distinguishing Changed Product

Product Mark
Date Code
Others
Demonstrated or Anticipated Impact on Form, Fit, Function or Reliability

Supplier Qualification Plan / Results

Littelfuse Requirements ALL Information Below is to be filled out by Littelfuse

PPAP Required Yes No Level Due date

Process Audit Yes No
LF Customer Approval Yes No
Appearance Approval Yes No
Additional Requirements
Littelfuse Approval Signature Signature Date
LF Procurement Representative
LF Engineering Representative (if needs)
LF Supplier Development Representative
Additional Requirements/Comments: