Atomic Loops APQP System

Supplier PCN (Product Change Notification)

Complete this form to notify Atomic Loops of any planned changes to product, process, or materials.

1. Supplier Identification

Supplier Name

Supplier Code / ID

Primary Contact Name

Contact Email / Phone

Supplier Address (if location change relevant)

2. General PCN Information

PCN Number

Date of Notification

Proposed Effective Date

Type of Change

Reason for Change

3. Product/Parts Affected

Part Number(s)

Part Name(s)

Customer Program(s)

Engineering Drawing No. / Rev

Affected Purchase Orders

Attachments

4. Details of Change

Description of Current Condition (Before Change)

Description of New Condition (After Change)

Justification for Change

Risk to Form-Fit-Function

Regulatory Impact (e.g., REACH, RoHS)

Any New Critical Characteristics Introduced?

Attachments

5. Validation and Qualification

Has validation/qualification testing been completed?

Description of Validation Activities

Results Summary

Is customer PPAP required?

Recommended Validation Plan (if pending)

Attach Test Reports (if completed)

6. Implementation Plan

Proposed Change Implementation Date

Dual Run / Parallel Production Dates (if any)

Inventory Impact

Traceability Strategy

Transition Risk Mitigation Plan

7. Customer Requested Actions

Sample Parts Available?

Sample Submission Date

Updated Documentation Provided?

Request for Waivers?

8. Supplier Approval & Submission

Supplier QA Representative Name *

Signature *

Date of Submission *

By submitting this PCN, you certify that all information provided is accurate and complete.Atomic Loops will review and respond within 5 business days.

Previous PCNs

List of previously submitted PCNs.

PCN Number	Date of Notification	Type of Change	Status
PCN-2023-001	2023-11-15	Raw Material Change	Approved
PCN-2023-002	2023-12-01	Manufacturing Process Change	Pending
PCN-2024-003	2024-01-10	Product Design Change	Rejected