Form PX-4893 at a glance
What it is: Certificate of Conformance, Index No. PX-4893, Issue No. 006 (Reference MNL-352209): prepare a Certificate of Conformance (CoC) addressing each PO line item, Contract Deliverable, or each partial shipment.
Who signs: The certification is attested to by an authorized representative of the supplier; and the certification system, including the procedures for completing, reviewing, and approving the certificate are described in the Company's administrative control system or Quality Assurance program.
Prior to completing this certification, the Supplier reviews and complies using the form instructions on page 2 of this document.
A filled-in Form PX-4893 example: a supplier certifies one line item
How to fill out Form PX-4893, box by box
A. Purchase Order (PO)/Contract Data
Entry 1 Enter the complete Pantex PO or Contract Number. Entry 2 Enter PO/Contract Revision or Amendment Number, (if applicable).
3. PO Line-Item Information: Entry 3 Enter as applicable, the PO Line Item Number (i.e., 1, 2, 3), quantity, heat/cast number, lot/batch number, serial number, and item identification (Tool number/Copy number).
B. Supplier/Source Information
Entry 4 Enter the legal Supplier company name, as stated on the PO or Contract.
5. Supplier Address (Street/City/State): Entry 5 Enter the Supplier business address, as stated on the PO or Contract.
C. Applicable Requirements
Entry 6 Enter the applicable design code/standard number and applicable revision, issue, edition, or addendum.
Entry 7 Enter the applicable specification number and applicable revision, issue, edition, or addendum.
8. Technical Drawings/Diagrams: Entry 8 Enter the applicable technical drawing/diagram and applicable revision, issue, edition, or addendum.
Entry 9 Mark the applicable box manufacturer published description/product description or manufacturers specification.
Entry 10 Enter other applicable requirements documents and applicable revision, issue, edition, or addendum.
D. Approved Changes/Deviations/Waivers/Substitutions/Nonconformances
Approved Changes/Deviations/Waivers/Substitutions/Nonconformances: Enter any approved changes. Reference change documentation control numbers as applicable. (Attach additional pages if necessary).
Unless otherwise directed in writing by the Procurement Specialist, do not deliver/ship materials/items/equipment if there are any changes, deviations, substitutions and/or nonconforming conditions that have not been previously submitted and approved.
E. Certification Statement
Certification Statement: Enter the Company name (or commonly used acronym). Print or type the authorized company certifying officials name, title, and date (Printed Name, Title, Date). Sign or otherwise authenticate by company certifying official.
The Supplier hereby certifies that the materials/items/equipment identified in Section A, and all required documentations, conforms in all respects to the stated PO/Contract requirements and that all exceptions, waivers, deviations, substitutions or nonconforming conditions are identified in Section D. Furthermore, information provided is accurate, complete, and true pursuant to 10 CFR 820.11 (see definition).
10 CFR 820.11 - Procedural Rules for Department of Energy (DOE) Nuclear Activities, Subpart A, Information requirements. The regulation states: Any information pertaining to a nuclear activity provided to DOE by any person or maintained by any person for inspection by DOE are complete and accurate in all material respects. No person involved in a DOE nuclear activity conceals or destroys any information concerning a violation of a DOE Nuclear Safety Requirement, a Nuclear Statute, or the Act.
More rules for Form PX-4893
Unless otherwise specified, the CoC accompanies each shipment.
All applicable form entries are completed.
A Supplier system-generated CoC may be attached and referenced and contains all applicable information required by this form, specifically the information requested in Sections A, B, C, D and E.
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.
Common questions about Form PX-4893
Where do I file it?
Transmittal: PanTeXas Deterrence, LLC Fax: 806-477-3891 Attn: Supplier Quality Or e-mail with a PDF file. supplierquality@pantex.doe.gov Place a copy with the shipment.
Sources
[1] Form PX-4893 (Issue No. 006), Certificate of Conformance, Pantex (the Official source link on this page).
