PART/DOCUMENT #	DEV. #	DATE OF REQUEST	START DATE	EXPIRE DATE
LIST ALL PART NUMBERS INVOLVED
PART/DOCUMENT NAME:	QUANTITY EFFECTED	TARGET EXPIRATION DATE - 60 DAYS MAXIMUM FROM DATE OF REQUEST
PROCESS	CONTROL NUMBERS (IF APPLICABLE)	CUSTOMER WAIVER / AUTHORIZATION : Example Alert / P.E.R.
Company (Check Box) Powers and Sons LLC Customer Supplier	Identify each container with copy of customer waiver / authorization (Check Box) YES NO
WORK CENTER [S]	MACHINE NUMBER [S]	# OF COPIES MADE	REQUESTED BY
DRAWING NUMBER	CHG. LEVEL	DWG. DATE
DESCRIPTION OF DEVIATION [MATERIAL, PROCESSING, SPECIFICATION, IDENTIFICATION]
A brief but complete explanation of the deviation requested and any Customer required special labeling.
REASON FOR DEVIATION
A brief but complete explanation of why the deviation is being requested.
A SUPPLIER’S REQUEST FOR DEVIATION MAY REQUIRE A PRELIMINARY CORRECTIVE ACTION.
IS DEVIATION INTENDED TO BE A PERMANENT CHANGE? YES NO
HAS A CHANGE REQUEST BEEN WRITTEN? YES NO LIST CR #
REASON FOR REJECTION [DATE & INITIAL]
Date, initial, and write a brief but complete explanation of why the deviation is being rejected.
REQ.	CONCURRENCES / TEAM MEMBER ASSIGNMENTS	REVOKE	APPROVE	REJECT	N/A	INVESTIGATE FEASIBILITY
MINIMUM REQUIRED APPROVALS
DESIGN ENGINEERING MGR. / TEAM	/
QUALITY MGR. / TEAM	/
MFG. MGR. / TEAM	/
ADDITIONAL APPROVALS [AS APPROPRIATE]
CHIEF OPERATING OFFICER / TEAM	/
SALES MGR. / TEAM	/
I.S. MGR. / TEAM	/
PURCHASING MGR. / TEAM	/
CONTROLLER / TEAM	/
H. R. MGR. / TEAM	/
PLANT SUPERINTENDENT / TEAM	/
PROD. CONTROL MGR. / TEAM	/
OTHER / TEAM	/