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<tbody>
<tr class="odd">
<td colspan="23"><strong>NOTE:</strong> Prior to completing this
certification, the Supplier shall review and comply with the attached
<strong><u>form instructions</u></strong>.</td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><strong>A.</strong></td>
<td colspan="21"><strong>A. Purchase Order/Contract Data</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">1.</td>
<td colspan="2">PO No.:</td>
<td colspan="7">     </td>
<td colspan="2">2.</td>
<td colspan="3">PO Rev No.:</td>
<td colspan="2">     </td>
<td>3.</td>
<td>PO Line Item:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">4.</td>
<td colspan="4">Contract No.:</td>
<td colspan="5">     </td>
<td colspan="2">5.</td>
<td colspan="4">Contract Amendment No.:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>B.</strong></td>
<td colspan="21"><strong>Supplier/Source Information</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">6.</td>
<td colspan="9"><p>Supplier:</p>
<p>     </p></td>
<td colspan="2">7.</td>
<td colspan="10"><p>Supplier Address (Street/City/State):</p>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">8.</td>
<td colspan="9">Source of Origin:</td>
<td colspan="12"><strong>CAUTION:</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3">Street:</td>
<td colspan="5">     </td>
<td colspan="2"></td>
<td colspan="11">The suppliers shall take all necessary actions and
precautions</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3">City:</td>
<td colspan="5">     </td>
<td colspan="2"></td>
<td colspan="11">to assure that this Certificate of Conformance(C of C)
is accurate,</td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3">State:</td>
<td colspan="5">     </td>
<td colspan="2"></td>
<td colspan="11">complete, and true, regardless of the actual source of
origin.</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3">Country:</td>
<td colspan="5">     </td>
<td colspan="2"></td>
<td colspan="11"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="12"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>C.</strong></td>
<td colspan="21"><strong>Applicable Requirements</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">9.</td>
<td colspan="5">Code/Standard No.:</td>
<td colspan="4">     </td>
<td colspan="6">Revisions/Editions/Addendum:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">10.</td>
<td colspan="5">Specification No.:</td>
<td colspan="4">     </td>
<td colspan="6">Revision/Editions:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">11.</td>
<td colspan="5">Technical Drawings/Diagrams:</td>
<td colspan="4">     </td>
<td colspan="6">Revision:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">12.</td>
<td colspan="5">Other:</td>
<td colspan="4">     </td>
<td colspan="6">Revisions/Editions/Addendum:</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><strong>D.</strong></td>
<td colspan="21"><strong>Approved
Changes/Deviations/Waivers/Substitutions/Nonconformances:</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="21">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><strong>E.</strong></td>
<td colspan="21"><strong>Nonconformance(s): Unless otherwise directed in
writing by the Procurement Agent, Do <u>NOT</u> deliver/ship
materials/items/equipment if there are any changes, deviations,
substitutions, or nonconforming conditions that have not been previously
submitted and approved utilizing Form 540.33, Information/Change
Request.</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>F.</strong></td>
<td colspan="21"><strong>Certification Statement</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
<td colspan="16">(Supplier), hereby certifies that the
materials/items/equipment identified in <strong>Section A</strong>
above, and</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="21"><p>all required documentation, conforms in all respects
to the stated Purchase Order/Contract requirements and that all
exceptions, waivers, deviations, and/or nonconforming conditions are
identified in <strong>Section D</strong>. Furthermore, information
provided is accurate, complete, and true pursuant to 10 CFR 820.11 (see
definition).</p>
<p>Authorized Certifying Official (See
Definitions/Instructions):</p></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">     </td>
<td></td>
<td colspan="5"></td>
<td></td>
<td colspan="6">     </td>
<td></td>
<td>     </td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7"><strong>Printed Name</strong></td>
<td></td>
<td colspan="5"><strong>Signature</strong></td>
<td></td>
<td colspan="6"><strong>Title</strong></td>
<td></td>
<td><strong>Date</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="23"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="23">See Instructions</td>
<td></td>
</tr>
<tr class="even">
<td colspan="23">C of C is Limited To One Page. Attached Additional
Pages On Supplier Letter Head If Required.</td>
<td></td>
</tr>
</tbody>
</table>

**Instructions**

**General**

Prepare a Certificate of Conformance (C of C) addressing each Purchase
Order line item, Contract Deliverable, and/or each partial shipment.
Unless otherwise specified, the C of C shall accompany each shipment.
All applicable form entries must be completed.

A Supplier system-generated C of C [may]{.underline} be attached and
referenced. All applicable information required on form 540.04 shall be
accounted for. Section **A** and Section **F** shall be completed in
their entirety, regardless of any attachments used.

**Definitions**

*Authorized Company Certifying Official*. The certification shall be
attested to by an authorized representative of the supplier; and the
certification system, including the procedures for completing,
reviewing, and approving the certificate shall be described in the
Company's administrative control system.

*Certification*. The act of determining, verifying, and attesting in
writing to the qualifications of personnel, processes, procedures, or
items in accordance with specified requirements.

*Certificate of Conformance*. A document signed or otherwise
authenticated by an authorized individual certifying the degree to which
items or services meet specified requirements.

*10 CFR 820.11.* Procedural Rules for DOE Nuclear Activities, Subpart
"A", Information requirements. The regulation states:

> \(a\) Any information pertaining to a nuclear activity provided to DOE
> by any person or maintained by any person for inspection by DOE shall
> be [complete and accurate in all material respects]{.underline}.
>
> \(b\) No person involved in a DOE nuclear activity shall [conceal or
> destroy any information]{.underline} concerning a violation of a DOE
> Nuclear Safety Requirement, a Nuclear Statute, or the Act.

**Instructions**

**Section A, Purchase Order(PO)/Contract Data**

Entry 1 Enter the complete INL Purchase Order (PO) number.

Entry 2 Enter PO Revision Number (if applicable).

Entry 3 Enter the PO Line Item Number, i.e., 1, 2, 3, etc....

Entry 4 Enter the INL Contract Number (if not a PO).

Entry 5 Enter the latest Contract Amendment Number (if applicable).

**Section B, Supplier/Source Information**

Entry 6 Enter the legal Supplier company name, as stated on the PO or
Contract.

Entry 7 Enter the Supplier business address, as stated on the PO or
Contract.

Entry 8 Enter the point of shipping origin by city, state, and country
if different than Block 7. The point of origin shall be the originating
location from which final shipment/delivery to the INL is made. If
different than Block 7, see CAUTION statement.

**Section C, Applicable Requirements**

Entry 9 Enter the applicable design code or consensus standard and
revision, edition, or addendum.

Entry 10 Enter the applicable specification and revision, edition, or
addendum.

Entry 11 Enter the applicable technical drawing/diagram and applicable
revision, edition, or addendum.

Entry 12 Enter Other applicable requirements documents and revision,
edition, or addendum.

**Section D, Approved
Changes/Deviations/Waivers/Substitutions/Nonconformances**

Enter any approved changes. Reference change documentation control
numbers as applicable. (Attach additional pages if necessary).

**Section E, Nonconformance(s)**

Self Explanatory.

**Section F, Certification Statement (see definitions)**

Enter the Company name (or commonly used acronym).

Print or type the authorized company certifying officials name, title,
and date.

Affix certifying official signature (indelible ink only - no stamps).