Central Instrument Facility Centre, IIT (BHU), Varanasi-221 005

Requisition Form (submit in duplicate)

Name of Instrument/Facility:..........................................................................................................................................

Nature of Work: UG/PG/PhD./ Project/ Consultancy/ Industry. (Pl. Tick)

User Information
Name of Indenter: ................................................................................................................................................................

Name of Supervisor/PI (in case of PhD/Dissertation/Project):...................................... Employee ID:..........................

Name of Department/School: ..............................................................................................................................................

Full address for communication: .......................................................................................................................................

Phone Number: ................................................ Email: .............................................................................................

Signature of the indenter Signature of recommending faculty member/PI

(HoD/Coordinator for UG students) with seal

Date: ................................... Date: ...................................

Number of Samples: Sample Code/Name:

1. 2. 3. 4. 5.

Nature of sample i.e. conducting, semi conducting, insulating, hybrid, biological, volatile, amorphous, crystalline,
corrosive, toxic, hazard etc.: Pl. Tick or specify if other

Other Information regarding samples: .............................................................................................................................

Parameters for operation: ..................................................................................................................................................

Special request (if any): .......................................................................................................................................................

Pl. Provide following information if related to your characterization:

a. Structure or formula (if known):
b. Melting point & decomposition temperature (approximate value): .............................................................................
c. Solvent for solubility (if required): ..................................................................................................................................
d. Characterizations required (Pl. Describe): ...................................................................................................................
e. Spectral/frequency range in details: ..............................................................................................................................
f. Size of design & file format:........................................................ Substrate Name &Thickness:.................................
g. Fabrication Type:

Sample required be to preserve or not: Yes/ No (If NO mode of disposal): ...................................................................

Special request (if any): .......................................................................................................................................................

Signature & Remark of Operator: Signature & Remark of Incharge:

Requisition/ Job Order Number (CIFC Office will provide) :
Payment:
Internal Users- A. From Faculty Research Support Grant/Project Contingency/ CPDA etc. (Pl. Tick)
(In case of project: Pl. Provide Project
code: )
B. Department/School Operating Grant
Pl. Deduct Rs. from the grant as marked above.
Signature with seal:
For A: Faculty Member/PI For B: HoD/Coordinator

External Users-In cash, Cheque/DD (In the name of Registrar, IIT, BHU, Varanasi) Pl. Provide details:

Signature of Professor In charge: