Service requisition form Job No.

Centralized Analytical Laboratory (CAL)

Block P, Ground Floor
Powder X-Ray Diffractometer (XRD, Model: XPert3 Powder, PANalytical)
(Location : P-00-06)
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 : Powder only
IC NO :
*To be filled by internal customer only
No. Sample Name & Description Scan Range () Exposure Time (s/step) Step Size (/step) Existing Elements

1.
2.
3.
4.
5.
6.
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.
Maximum of 6 samples can be submitted per request. Page 1 of 3
Results can be collected using a blank cd-r only. CAL_Aug2016
The sample volume should be able to fill in of amount 1.848 cm3.