VENDOR SAMPLE QUALIFICATION REQUEST CUM REPORT

Request From: Quality Assurance (QA)                  To: Quality Control

Name of the material	Category (Raw material, Packaging Material, API, Excipient, Preservative etc.)
Vendor Name	Batch No’s
In-house Specification: Attached         (Y/N)	Vendor Specification: Attached         (Y/N)
Sample Size	Type of Analysis (Complete Analysis Recommended)

Quality Assurance
Name	Designation	Signature	Date

Report from QC:
Remark From QC	Material complies / does not comply with specification.
Enclosures	Analytical data                                            1
	Certificate of Analysis (COA)                       1

Quality Assurance
Name	Designation	Signature	Date