DEPARTMENT OF SCIENCE AND TECHNOLOGY

Regional Office No. IV-A (CALABARZON)

Regional Standards and Testing Laboratory
Jamboree Road, Timugan
Los Baños, Laguna
Telefax: (049)536-4390 e-mail: rstl_dost4a@yahoo.com; dost4a@dost.gov.ph
URL: http://region4.dost.gov.ph
__________________________________________________________________________

REQUEST FORM
Fields with a check (√) mark SHALL be filled out by customer. Please write LEGIBLY as this information will be reflected in the Result of Analyses.

√ Company/Customer: _______ To be filled-out by the laboratory:

Requisition I.D. No.: R4AL1-______________
√ Address: ________________________________________________________ Date: ________________________________
Date test report prepared: ________________
√ Contact Person: __________________________________________________
√ Tel/Fax. No.:__________________ √ Mobile No.: ___________________ √ E-mail Address: _____________________
√ Nature of Business:
 Food/Beverage  Construction  Electronics/Semiconductors  Chemicals/Petrochemicals  Academe
 Agriculture  Pharmaceuticals  Transport (Shipping, Aviation)  Mining  Government
 Metals & Engineering  Hospitals  Plastics/Rubber Manufacturing  Trading  Others ________________
√ Sample Type:
 Food/Beverage  Drinking Water  Wastewater  Surface water  Processed water  Others ____________
Sample √ Sample Designation/ √ Sample Description √Date & Time √ Analysis Method
Code Identification/Source (sealed or unsealed, of Sampling Required
volume, container type,
labeled or unlabeled,
other observation)

Estimated date of completion:

Customer’s Special Instruction/Remarks:

√ Result of Analyses Mode of Release:  pick-up  thru fax, then pick-up  thru email, then pick up  courier (with additional charge)

√ For mode of release thru fax/e-mail, please accomplish the following:

“We are requesting RSTL to forward to us the result of analyses through facsimile/e-mail. We understand that this document is not the official
Result of Analyses.”

_____________________________ ___________________ ________________

Printed Name of Authorized Representative Signature Date

√Other Requests/Instructions:
 None  With regulatory/standard limits  Others, please specify: ________________________

To be filled out by the Receiving Officer:

Upon receipt, the sample requirements submitted have been checked and that sample is:
 Within specifications  Out of Specifications: State the reason: __________________________________

I do hereby agree to the terms and conditions and am aware of relevant RSTL policies stated at the back of this form.
√ √
Customer's Representative Date RSTL - Representative
Print Name and Signature

OP-007-F1 Revision: 8
Effectivity Date: April 25,2022
Page 1 of 3
 TERMS AND CONDITIONS

1. RSTL agrees to provide testing services in accordance with:

(a) this Request Form (RF) and these Terms and Conditions, unless otherwise specially agreed in writing
(b) the Customer's specific instruction only, or of any other party authorized by the Customer;
(c) test methods and procedures considered by RSTL to be appropriate based on the technical, operational and/or financial grounds.

2. RSTL agrees to use reasonable diligence in the manner of performing the test services but no warranties are given and none may be implied
directly or indirectly relating to RSTL's test results and facilities. In no event shall RSTL be liable for collateral, special or consequential
damage, any error of judgment, fault or negligence of its officers or employees.

3. RSTL agrees to keep test results confidential and releases results to parties other than the customer, only upon authorization by the latter,
or if required by law.

4. RSTL is responsible in the management of all information obtained from the customers or their representatives. No information of the
customers or their representatives will be used in any form of publication by the laboratory without the former’s consent. Any information
about the customer or their representative from another source are confidential between the customer and the laboratory. Unless permission
is granted, the source of information is not shared to the customer.

5. Customer agrees to have the job done according to the stated schedule. No cancellation of jobs will be honored.

6. The Customer shall:

(a) ensure that instructions to RSTL and other relevant information are provided in due time to enable effective performance of test services;
(b) supply, if required, any special equipment, tools, devices and personnel necessary for the performance of test services;
(c) provide access to RSTL personnel on information or localities necessary for the contract of test services;

7. This contract is only for such items/materials and work as specified herein. Any other additions or amendments after acceptance will be
separately chargeable.

8. Complaint, question or dispute that may arise by reason of the test service rendered by RSTL shall be referred to an arbitrator or panel of
arbitrators chosen by parties. Complaints or questions shall be given course only if it is in writing. The decision or recommendation of the
arbitrator or panel of arbitrator shall be final and binding on the parties.

9. This contract shall in all respects be constructed and operate as a contract made in the Philippines and in conformity with laws obtaining in
said jurisdiction.

10. Full payment of the testing services shall be made before the Result of Analyses is released.

RELEVANT RSTL POLICIES

Storage of Test Items

11. Tested samples shall be stored for one week after the release of Result of Analyses or until the recommended maximum holding time for
analyte/s has been reached.

Result of Analyses
12. Result of Analyses is released upon presentation of the claim stub. Results of Analyses are issued only once and "Certified true copy" can
be issued after a written request was presented by the customer. Maximum of two (2) copies can be provided for free. A corresponding fee
amounting to ten (PhP 10.00) pesos per copy will be charged for every excess.

13. The Customer must present the claim stub when claiming the Result of Analyses. In case of lost claim stub, the person who claims the Result
of Analyses must present a signed letter of authorization from Company/Customer.

14. The following entries in the Result of Analyses cannot be changed:

(a) Date received/started
(b) Date Sample Submitted
(c) Sampling Date
(d) Customer's sample designation/description;
(e) Customer's name/address.

15. Customer is given fifteen (15) calendar days after receipt of Result of Analyses to request for changes other than what has been stated in
Item 14. Changes on test results are all subject to retest.

OP-007-F1 Revision: 8
Effectivity Date: April 25,2022
Page 2 of 3
 DEPARTMENT OF SCIENCE AND TECHNOLOGY
REGIONAL OFFICE NO. IV-A (CALABARZON)
Regional Standards and Testing Laboratory

DATA PRIVACY NOTICE: RSTL value your privacy and will keep your personal information confidential. In signing thereof, you hereby
authorize the Department of Science and Technology CALABARZON (DOST-CALABARZON) to collect and process the data indicated herein
for the purpose of reporting test results. Any personal information submitted herein will be treated with utmost confidentiality pursuant to RA
10173 (Data Privacy Act of 2012). Thank you. (Please also read the Customer Consent Form)

CUSTOMER CONSENT FORM

I, whose name and signature appears on this page, hereby expressly agree, consent, and authorize DOST-CALABARZON RSTL to collect and process the
following personal information related to me:
1. Customer/Company 2. Address 3. Contact Number 4. Contact Person
5. Email

I agree that the above-mentioned personal information shall be processed for any of the following purposes:
1. To provide means of communication 2. Issuance of Result of Analyses 3. Customer Satisfaction Measurement
for the Laboratory and the Customer.

4. Documents for Annual Reports,

Activity Reports, and other related
publications

I agree that the above-mentioned personal information shall be processed in the following manner:
1. Storage in a database/information system 2. Storage in filing cabinets 3. Storage on computer files

I agree that the above-mentioned personal information may be shared/disclosed to the following recipient/s with the following purpose/s:
Recipient Purpose
1. DOST CALABARZON – RSTL For documentation and/or billing statements
2. Other Agencies (please specify): (state reason/purpose below)
_______________________________ ___________________________________

I agree that the above-mentioned personal information will be retained or stored for as long as the purposes for which they are being processed have not
been satisfied.

√__________________________________ √______________
(Signature over Printed Name) (Date)

I am aware of my rights under the Data Privacy Act, including the following:
 The right to access my personal information  The right to be informed of the existence of processing my personal
information
 The right to make corrections to my personal  The right to damage
information
 The right to object to the processing of my personal  The right to lodge a complaint before the National Privacy Commission
information
 The right to erasure or blocking of my personal
information

I understand that in case of complaints, concerns, or questions regarding the processing of my personal information, I may address them to:
Engr. Francisco R. Barquilla III (Data Officer)
Department of Science and Technology – CALABARZON
Jamboree Road, Brgy. Timugan, Los Baños, Laguna
Telephone No.: (049) 536 4997 / 4894
Email Address: dost4a.ord@gmail.com/rstl_dost4a@yahoo.com

This consent and authorization remains valid and subsisting for a limited period consistent with the purpose above or until otherwise revoked or cancelled in
writing.
OP-007-F1 Revision 8
Effectivity Date: April 25,2022
Page 3 of 3

----------------------------------------------------------------------------------------------------------------------------- ---------------------
Requisition I.D. No.: R4AL1-______________________________ O.R. No.:___________
Estimated Date of completion___________________ Date of transaction:_____________
THIS SERVES AS YOUR CLAIM STUB.
(If you have questions/clarifications, you may contact us at (049) 5364390; rstl_dost4a@yahoo.com)