CENTRAL POWER RESEARCH INSTITUTE

Name of the Unit / Division: DIELECTRIC MATERIALS DIVISION

Format No: CPRI/QAF/01 Issue No. 01

Date of Issue: 15-11-2005
Revision No.04
Date of Revision: 31/08/2016 Sheet 1 of 2

Customer Request Form

Name & Address of the Customer :

Sample to be tested / calibrated :

Rating of the sample to be tested :

Description of the test/calibration sample :

Type and Serial No. :

Manufacturers Details :

Drawing Nos. :

Customers Requirement :
Criteria for Evaluation :
No. of Samples :
Condition of sample submitted :

Sample storage /Handling/Disposal
Details of test/calibration requested
: a) Taking back the sample after testing :Yes / No
b) Will not take back the sample,
CPRI can scrap and dispose it off : Yes / No
Note: If samples are not collected as in (a) within
15 days from the date of testing it will be
atomatically scrapped.
:

Specific instructions (if any) for

mounting and connection :
Name of the witnessing persons :
Customers Representative :

Other than Customer :

Test Report to be despatched to :

Test report Despatch mode :
Number of extra copies :

SSI Discount : Applicable/Not Applicable

(If applicable customer to provide necessary

Documents.) Billing to be done accordingly.

Note: 1) CPRI Website will publish information on manufacturers name, products tested,
test report number & date of issue and corresponding unique sample code number.
 2) The terms & Condition document is made available while making the offer from CPRI
for testing. The document is also available in CPRI web site www.cpri.in . Customers
are requested to go through the document carefully before proceeding for testing.

I/We have read & understood the terms and condition for testing at CPRI and agree to the
conditions stipulated there in.

Customers Name & Signature with Date

CENTRAL POWER RESEARCH INSTITUTE

Name of the Division: DIELECTRIC MATERIALS DIVISION

Format No: CPRI/QAF/01 Issue No. 01

Date of Issue: 15-11-2005
Revision No.: 04
Date of Revision: 31/08/2016
Sheet 2 of 2
(To be filled by the laboratory)

Whether laboratory has capability to :

take up to the work

:
Test/ Calibration subcontracted

Name & signature of Test :

Engineer/Test In charge for
accepting the job, with date

(To be filled up by the laboratory after testing, if applicable)

 :
Discrepancies if any noticed testing

Communication to Customer for his :

By Telephone /in person
approval of the Discrepancies

(Record of the discussion)

Name & Signature of Customer with date

(if present)

Name & Signature of Test

Engineer/Test In Charge (with date)