Application Form

(elemental Analysis)
Applicant Name name & email add. of the person in charge for pay

name seal

Affiliation(applicant)

mail:

Lab. Ext. & email address Budget cord *We can't accept any samples without this number

Ext. :

mail : Date year month day

sample number

Lab. No. Personal No. sample No.

Theoritical office use Theoritical office use

check element check element
w % date result w % date result

C F

H Cl

N Br

S I

O Ash

　　Expected molecular formula

　　Possible impurity(e.g. solvent)

　　Expected chemical structure　(This item can be passed　)

　　備考 　Other cautions：

State of sample □ Powder/Crystal/ □ Liq/ □ Oil
□b.p. / □m.p. ℃
stability in air □ stable /　　□ unstable
photostability □ stable /　　□ unstable
hygroscopicity □ no /　　□ yes
sublimation □ no /　　□ yes
explosibility □ no /　　□ yes
office use CHN(　） halogen・S(　） O（　） others（　）

Division of Materials Analysis Suzukake-dai, Technical Department, TIT　Ext：5278