(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.) 

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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.
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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. 

mina form fqa2 ver 11/22/99a