Organic Synthesis Research Laboratory REQUEST FORM

Organic Synthesis Research Laboratory
Institute of Science
Contact ;Irma:03.3258.4295/ Zaleha : 03.3258.4294
REQUEST FORM
FOURIER TRANSFORM INFRA-RED
Customer Information
Name of applicant:…………………………………………………………………………………………………………… Date :…………………………………………
Email & Contact Number:……………………………………………………………………………………………………………………………………………….………
Research grant (if applicable):……………………………………………………… Signature of applicant: ………………………………………..…………
Signature & Stamp of supervisor (if applicable):………………………………………………………………………………………………………………….…
Billing address:
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Sample Information
Number of sample : ……………. (Please submit one form for every 3 samples)
Sample Code:…………………………………
Sample Code:…………………………………
Sample Code:…………………………………
Type of Sample (Please circle where
appropriate)
Type of Sample (Please circle where
appropriate)
Type of Sample (Please circle where
appropriate)
Fine Powder Film
Fine Powder Film
Fine Powder Film
Liquid
Gel
Liquid
Gel
Liquid
Gel
Other request:
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Other request:
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Other request:
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FOR OFFICE USE ONLY
Date Completed
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Total Cost(RM20/sampel) : ……………………………………………………..
Officer in Charge
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Remarks
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