20__/FSM/FLS/__ ( )

FACULTY OF SCIENCE AND MATHEMATICS

No Rujukan JPPS
UNIVERSITI PENDIDIKAN SULTAN IDRIS 20__- FSM/J__ /__-____
Tel: 015-4879 7314 / 7305 (P)|Fax: 015-4879 7296
(BIL ___/___)
Email : instrumenfsm@upsi.edu.my UPSI/FSM/JPPS(Pin 04)

APPLICATION FOR SAMPLE ANALYSIS

FLUORESCENCE SPECTROMETER

PART A: APPLICANT INFORMATION

Applicant Name :
Matrix / Staff No. : Phone No. :
Programme : Department :
Supervisor Name :
Project / Research Title :

Vot / Grant No. : Current Balance :

Please tick (/) : Undergraduate Postgraduate (coursework @ Thesis)/GRA/RA External

PART B: SAMPLE INFORMATION

Number of Sample :
Sample Condition :
Sample Properties : Toxic Carcinogenic Normal

PART C: DECLARATION

STUDENT / STAFF DECLARATION SUPERVISOR / LECTURER DECLARATION

I acknowledge that this student is under my supervision.
I acknowledge that all information given above is true. I will be
* I agree to pay the cost set by the Faculty of Science and
responsible for any damages that occurred due to falsification of
Mathematics.
the information.
*(If Applicable Only)

(Signature) (Signature & Stamp)

Name : Name :
Date : Date :

PART D: APPROVAL BY SCIENTIFIC INSTRUMENT COORDINATOR

SCIENTIFIC INSTRUMENT COORDINATOR APPROVAL: APPROVED / NOT APPROVED

Reason for not approved :

(Signature & Stamp)

Name :
Date :

OFFICE USE

Operator Name : PAYMENT RATE

Received Date : RM 15.00/sample

UPSI
RM 30.00/raw sample
Completed Date : (Preparation RM 50.00)
RM 50.00/sample
Remarks : External
(Preparation RM 50.00)

Urgent Analysis RM 70.00/sample

TOTAL AMOUNT (RM) : (Internal & External) (Preparation RM 50.00)