Disclosure information per Section 4(a) of P.L. 106-34, 'Fastener Quality 
Act Amendments Act of 1999'(FQA99).

date: ___/___/______

to:  ______________________________________________________________
reference your purchase order number:______________________________
dated: ___/___/______

(supplier company):__________________________________________________
certifies that the some/all of the goods listed on the purchase order 
number above were:

___ electroplated after the initial manufacturing process from parts that 
    are covered by FQA99 and a new or amended "record of conformance" 
    is enclosed.
___ mechanically modified from existing parts that are covered by FQA99 
    and a new or amended "record of conformance" is enclosed.
___ mechanically modified from raw material to customer specifications 
    which render the part covered by FQA99 and the "record of conformance" 
    is enclosed.
___ other:__________________________________________________________
    ________________________________________________________________
    ________________________________________________________________

This form completed by: _____________________________________________
___ customer copy   ___ file copy

mina form fqa3 ver 12/05/99