UCT No: _________________ Sample Lab No: _______________ DCC COPY

CENTRAL LABORATORY
UNIVERSITI MALAYSIA PAHANG
LEBUHRAYA TUN RAZAK, 26300 KUANTAN
PAHANG DARUL MAKMUR
PHONE : 09-5493342/8036 FAX : 09-5493353

DOC NO : CENLAB/F/003
REV :03
EFFECTIVE DATE : 01/01/2016 REQUEST FORM

A. CUSTOMER INFORMATION

Name
Company/Institution
Address

Student ID
Email
Tel No Fax No

B. SERVICE INFORMATION

Testing Training Consultation Others

No Description/Type of Testing/Parameter Method/Equipment

Return Sample to Customer

Dispose by Central Laboratory (Refer to CENLAB/F/030 Disposal Form)

Customer’s Signature Recipient’s Signature

C. SAMPLE INFORMATION (fill by Central Laboratory’s Staff)

Date Received
Sample Lab No
Sample Marking
Sample Description
No of Sample Normal Abnormal
Action for abnormal
Remarks

D. VERIFICATION (fill by Technical Services Unit)

Verify by : _______________________ Date : ___________________

 FINANCE COPY

LAB NO: _____________

CENTRAL LABORATORY
UNIVERSITI MALAYSIA PAHANG
LEBUHRAYA TUN RAZAK, 26300 KUANTAN
PAHANG DARUL MAKMUR
PHONE : 09-5493342/8036 FAX : 09-5493353

DOC NO : CENLAB/F/083 TECHNICAL SERVICE AGREEMENT

FORM
REV :00
EFFECTIVE DATE : 01/10/2014

GRANT NO/PTJ CODE

SUPERVISOR/
GRANT OWNER
STUDENT NAME

I hereby declare that I agree with the technical service’s price quoted by Central Laboratory and
would like to carry out a technical service provided by Central Laboratory. I also agree that Central
Laboratory will not be held responsible for any services that I provide to the third party based on the
technical service results that I obtained from Central Laboratory.
Details of the technical service as follow;

TYPE OF TECHNICAL SERVICES QUANTITY PRICE TOTAL PRICE

(TESTING/CONSULTATION/TRAINING) (RM) (RM)

GRAND TOTAL RM

SUPERVISOR/GRANT OWNER DEAN OF FACULTY LABORATORY ANALYST

(sign & official stamp) (sign & official stamp) (sign & official stamp)

DATE DATE DATE

* Please stamp every pages