Download as pdf or txt
Download as pdf or txt
You are on page 1of 2

PERMULAB SDN BHD (392059-X)

A-G-16, MERCHANT SQUARE@TROPICANA, JALAN TROPICANA SELATAN 1, TEL : 03-7883 0068


PJU 3, 47410 PETALING JAYA, FAX : 03-7883 0065
SELANGOR DARUL EHSAN, MALAYSIA EMAIL : info@permulab.com.my
WEB: www.permulab.com.my

ANALYSIS REQUEST FORM Master Copy

PAYMENT: TERMS / PAID / Not PAID / DEPOSIT Form 1.doc


Pg ( / )
*Please fill in this form and send together with your sample *Kindly tick √

Lab. Reg. No : Address :


*Company Name :
*Report Attention To :
*Sample Source : Tel No. :
*Sample Description : Fax No. :
*Sampling Date : *Sender Name :
Receive Date : *H/P No. :
*No of Report Required : 1 (W) / 2 (F) / ………. copies Turnaround Time : days
*Report : Separate / Combine Report sent via : Fax
Email
Type of Industry: Pulp and Paper Industry T Textile Industry Fermentation and Distillery Industry
(*For water sp only) Other Industries: Please Specify

No. *Sample Marking *Test/ Parameter Standard Remark /


Method ref

Total number of sample : ………………………


Note to accounts personnel : Report bill to …………………………………………………. (if applicable)

Actions to be taken by Information

Customer request date for completion of analysis: ………………………

Sender Name & Signature Received By

…………………………. …………………….
Name : Name:
Date : Date :

You might also like