GSQRM Acknowledgement Form, Revision C

Acknowledge your Company’s ability to meet the requirements of each Section below by
answering Yes or No for each requirement.
If a section is not applicable to your business please use No
REQUIREMENT YES NO
Quality Certifications ☒ ☐
Contingency Plan ☒ ☐
Customer Notification ☒ ☐
Parts Requiring Qualification (PPAP) ☒ ☐
First Article Inspection (FAI) ☒ ☐
Record Retention and Certifications (CERTS) ☒ ☐
Reportable Substances Honeywell Product Stewardship ☒ ☐
Identification and Traceability ☒ ☐
Corrective Action Report ☒ ☐
Deviation. Requesting a Deviation / Waiver ☒ ☐
Foreign Object Damage (FOD) Control ☐ ☒
Component Solderability ☐ ☒
Intrinsically Safe Components ☐ ☒
Shelf Life Control ☒ ☐
Electrostatic Discharge ☐ ☒
Honeywell Owned Tools ☐ ☒
COTS ☐ ☒
Counterfeit Parts Prevention ☐ ☒
Supplier Request for Engineering Change ☒ ☐

Supplier to complete information below and return to requestor

Supplier Company Name:

Name of Person:

Title:

Date:

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