Form A (UM user)

X-RAY LAB
Department of Geology
Faculty of Science
University of Malaya

APPLICATION FORM FOR XRD ANALYSIS

Applicant details FOR OFFICIAL USE Date received:
_____________
Name : Nozimjon TUYGUNOV
Institution address : Faculty of Dentistry, University of Malaya Reference No.:
XRD/__/____

Date completed:
_____________
Contact No. : +998935890011

E-mail : nozimtuygunov82@gmail.com

Samples Information

Samples Name : Glass ionomer cement (Powder)

No. of samples :

Name of Supervisor : ____________________________________________

I agree to make payment in accordance to the quotation issued by Department of Geology, Faculty of Science,
University of Malaya, Kuala Lumpur. (Please √ at relevant box)

* Lab handling : RM 50 per service

BSc Student Dept. of Geology : Free Student University of Malaya : RM 100 per sample

Faculty of Science Other Faculty/university

Raw data: RM60 per sample Raw data: RM100.00 per sample

Phase Identification: RM120 per sample Phase identification: RM200 per sample

Clay mineral identification: RM200 per sample Clay mineral identification: RM250 per sample

Clay mineral quantification: RM300 per sample Clay mineral quantification: RM400 per sample

Jabatan Geologi, Universiti Malaya, 50603 Kuala Lumpur, Malaysia

(Department of Geology, University of Malaya, 50603 Kuala Lumpur, Malaysia)
Tel : 603-79674203, Faks : 603-79675149 E-mel : sci_geo@um.edu.my
Laman Web: http://geology.um.edu.my
Research Fund Information

Research Grant (eg. PPP, Science Fund etc) : __________________________________

Research Grant No. : __________________________________

*Please enclose a copy of Expenses list for an updated account of your research grant.

Confirmation Important Information

Applicant’s signature : 1. Please submit your application form to Ms Fasyarina

quotation will be issued by Department of Geology
prior to the analysis.
________________
Date: 2. Analysis will be done only after the Department of
Geology has received the copy of Invoice Commitment
which has been certified by supervisor and Head of
Supervisor of Applicant :
Department.

________________ Incomplete application form will not be entertained

Date :

For any queries, please contact

Supervisor of XRD :
The coordinator: Dr. Muhammad Hatta Roselee at
03-79674227 (hattageo87@um.edu.my)
Sc. Officer Assistant : Ms Nurfasyarina Azureen at
03-79674031(fasyarina@um.edu.my)
_________________
Date :
Official Stamp :

Head of Department of Geology :

_________________
Date :
Official Stamp :