ASTM D5063-90(2012)

Number:
Date:

Generic Type:

Manufacturer's Designation:

Specification Number:

Formula Number:

Number of Components:

Component Identification (if applicable):

Color:

Name and Address:

Purchase Order Number:

Release Number (if applicable):

Part Number (if applicable):

Item Number (if applicable):

Stock Number (if applicable):

Name and Address:

Seller's Representative:

(Include Telephone Number)

Batch Number:

Lot No.:

Date of Manufacture:

Date of Expiration of Certification:

This is to certify that the above material being furnished has been manufactured in accordance with the specification and meets all specification requirements contained in the above purchase order.

 NAME AND TITLE SIGNATURE DATE