Service requisition form

Job No.:

Centralized Analytical Laboratory (CAL)

Block P, Ground Floor
Inductively Coupled Plasma (ICP-OES, Model: Perkin Elmer; Optima 8300)
(Equipment location : 04-00-04)
Name :_________________________________________________ Company Name: …………………………………………………….

ID No :______________Contact No:__________________________ Address: ………………..……………………………………………….

Status :□ FYP □ MSc □ PhD □ RO □Others:_________________ ………………………………….. ………………………………………….

Department :□ME □ EE □CHE □CV □GPE □FASD

Covenant of Applicant.
Project title :__________________________________________________
I ………………………. Have read and fully understood
Cost Center :_________________________________________________ and agreed to abide by the “General Information,
Terms and Conditions Relating to Acceptance of
Supervisor :_________________________________________________ Projects for Testing and Laboratory Rules and
Regulation”.
E-mail :__________________________________________________
Signature :……………………………………
Sample Type : Clear aqueous solution
IC NO :……………………………………

Date :……………………………………
*To be filled by internal customer only
Expected Standard
No. Sample Name & Description Element Remarks
Concentration (ppm) Concentration (ppm)
1.
2.
3.
4.
Endorsed by:

________________________
(Supervisor/Project Leader)

FOR DEPARTMENT/CENTRE/SECTION USE:

Services applied can/cannot be provided. Proposed date of Testing :
Signature:
Name:
Designation:
Date:

Result & Sample Collected By:

Signature:
Name:
Date:

Customer Feedback form : □ Yes □ No

Note:
Please put your samples in glass vials with proper labeling and send to CAL
Person in-charge: Mr Asnizam Helmy B Tarmizi Email: asnizamhelmy@utp.edu.my Tel: 05-368 8210
Maximum of 4 samples can be submitted per request. Page 1 of 3
Results can be collected using a blank cd-r only. CAL_July 2018