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(The form below may be used when utilizing the 'All fasteners are exempt from FQA99 (P.L. 106-34) if they are packaged in a container of 75 pieces or less and are labeled for use as a spare, substitute, service, or replacement part." rule.)

Exemption certification per section 3(6)(B) of the Fastener Quality Act P.L. 106-34, 'Fastener Quality Act Amendments Act of 1999'. date: ___/___/______

This certifies that goods purchased from:

(suppliers company name) __________________________________________

by: (purchasers signature or name) ___________________________________

of: (purchasers company name) _____________________________________

on purchase order number:__________________________________________

dated: ___/___/______ are for use as either a spare, substitute, service, or replacement part per section 3(6)(B) of the Fastener Quality Act P.L. 106-34, 'Fastener Quality Act Amendments Act of 1999'. I further acknowledge that these parts will be packaged in containers of 75 pieces or less.

mina form fqa2 ver 11/22/99a


If you are going to use the 75 piece exemption rule then, it is probably a good idea to have a copy of the form, completed by the customer, in your customer records to show that you have complied with that provision of FQA99. You may revise the above form to suit your particular organization.
Click here for a text (.txt) version of this form.
Press notice: You are welcome to freely use any MINA materials. Just credit MINA as the source. Be advised that any communications from MINA should not be taken as legal advice.

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