Supplier Quality Survey

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Maude Black
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1 Section 1: Supplier Information (Viasat Internal Use Only) New Prospective Supplier (Pre-Award) Section 1 Required Existing Supplier (Follow-Up) Section 1 Required Renewal Section 1 Not Required SUPPLIER NAME: SUPPLIER #: VIASAT REQUESTOR NAME: VIASAT REQUESTOR ADDRESS: COMMODITY(IES) INITIALLY REQUESTED: ORG NUMBER(S) INITIALLY REQUESTED: MAS (all Orgs) 10 (Carlsbad) 75 (AS) 30 (Tempe) 08 (Germ.) 14 (Clev.) 19 (Wildblue) 10 (Marlb.) P/N TO BE ORDERED INITIALLY: PROGRAM(S): Section 2: Supplier Information (Supplier) BUSINESS NAME: DBA (IF DIFFERENT FROM ABOVE): NAME OF PERSON WHO COMPLETED THIS FORM: ADDRESS: PHONE NUMBER: ADDRESS (No. and Street Name): CITY, STATE, ZIP: LENGTH OF TIME IN CONTINUOUS BUSINESS: Years FACILITY SIZE: Sq. Ft. (Ft 2 ) TOTAL NUMBER OF EMPLOYEES: ADMIN QUALITY MANUFACTURING ENGINEEERING Company Quality Address (prefer Group ) for electronic auto NMR notification: Purchase Order s Point of Contact Quality s Point of Contact PR Rev 016 (10/1/2018) Page 1 of 6

2 Section 3: Scope of Approval Classification ITAR (International Traffic in Arms Regulations) ITAR Parts (22 CFR ) ITAR Compliant & Registered - Expiry Date: Provide PDF: Registration with the Directorate of Defense Trade Controls is a requirement of ITAR Compliance Not ITAR compliant Are your processes capable of providing products compliant with the latest REACH standard? Can you attach or provide upon request your company s latest REACH declaration form or complete Viasat form PR if needed? Are your processes capable of providing products compliant with the latest ROHS standard? Can you attach or provide upon request your company s latest ROHS declaration form or complete Viasat form PR if needed? ISO (Environmental) Certified - Expiry Date: Provide PDF: Do you have an Environmental Policy? Provide PDF: Do you have an Environmental Management System? Do you follow the EICC Code of Conduct? Counterfeit Electronic Parts program per IAW SAE AS5553/SAE AS6081 is in place - Expiry Date: ISO 9001 (QMS) Certified - Expiry Date: Provide PDF: AS9100 (QMS for Aerospace Industry) Certified - Expiry Date: Provide PDF: ISO/IEC (QMS for Laboratory Competence) Certified - Expiry Date: Provide PDF: ISO (QMS for Medical Devices) Certified - Expiry Date: Provide PDF: ISO (IT Security) Certified - Expiry Date: If No, do you have a plan to be certified? Provide PDF: Expected Certification Date: PR Rev 016 (10/1/2018) Page 2 of 6

3 TL 9000 (QMS for Telecommunications) Certified - Expiry Date: Provide PDF: TS (QMS for Automotive related products) Certified - Expiry Date: Provide PDF: OHSAS (Safety) Certified - Expiry Date: Provide PDF: Do you have a Health & Safety Program? - Established Date: IPC-A-610 (Acceptability of Electronics Assemblies) Certified - Expiry Date: IPC/WHMA-A-620 (Requirements and Acceptance for Cable and Wire Harness Assemblies) Certified Expiry Date: IPC J-STD-001 (Requirements for Soldered Electrical and Electronic Assemblies) Certified Expiry Date: IPC-7711/7721 (Rework, Repair and Modification Program) Certified - Expiry Date: Other QMS certifications: Provide your company s QA Manual as PDF file(s) List any WORKFORCE CERTIFICATION(S) (AWS, IPC, JSTD, MIL, ETC.) Primary Business/Products: PR Rev 016 (10/1/2018) Page 3 of 6

4 Type of Business: Integrator Domestic EMS International EMS Domestic PWB International PWB Interconnects (Cables) Machining Sheet Metal Distributor Section 4: Contact Information Contacts Name Title Phone Address Executive Operations Quality Production Annual Sales (last year) in $USD Present Number of Customers: $ USD Percentage of business: % Commercial % Government PR Rev 016 (10/1/2018) Page 4 of 6

5 PRINCIPAL CUSTOMERS Company Name City, State, Country Product(s) Sold % of Overall Business Delivery Rating Quality Rating % % % % % % % % % Supplier Representative Signature: Date: Supplier Representative Printed Name: The Section Below is for Viasat Internal Use Only: Status: ECO CO- If Conditional Approval, SCAR - Commodity Codes - initial approval(s) Org # to be approved MAS (all Orgs) 8 (Germ.) 75 (AS) 10 (Carlsbad) 10 (Marlb.) 30 (Tempe) 14 (Clev.) 19 (Wildblue) PR Rev 016 (10/1/2018) Page 5 of 6

6 Additional Notes: Restriction: Specialize in: Audit Date: Trip Report Posting SAS Completion & Submitted Date (required for Integrator, EMS, PWA): Site Audit Conducted by : (Name) SAS score % MM/DD/YYYY Expiry Year: (Dec 31) (expiration: current year + 3 years) Oracle: ASL Business Classification update Authorized By (QA) QE s Signature & Name Approval Date: PR Rev 016 (10/1/2018) Page 6 of 6

Q Microwave, Inc. Resp Name Date Description

Q Microwave, Inc. Resp Name Date Description NOTES (1) Revision of all sheets is same as the cover page. REVISIONS Rev Description Date Approval SEE REVISION E FOR PREVIOUS REVISIONS F 5657-292 / UPDATE 10-13-14 R.S. G 5657-837 / UPDATE 3-26-15 R.S.