INTERNATIONAL CENTER FOR CHEMICAL AND BIOLOGICAL SCIENCES   [ICCBS ]
                                                                                                                                      P.C.M.D
                                                                                               H.E.J.                                 .                                            L.E.J.                                     T.W.C.                              I.A.C.
                                           Document Title:  Mass Spectrometry Sample Submission Form
                                               Doc.                    ICCBS/04/99(3                                        Rev.                        01               Issue                           1                    Rev. Date:                                              3-11-2015
                                             No:                       )-01                                               No                                            No:
                                                                                                         Mass Spectrometry Sample Submission Form
                                                                                                                                                                    For Institute Only
                                           Incomplete form will not be considered!
                                           General Information:                                                                                                                                                    Date of Submission:                                                                                 
                                           Name of Student:                                                                                                              Intercom no./Lab No.                                                                                                                              
                                           Name of Supervisor:                                                                                                           Signature of Supervisor:                                                                                                                          
                                                                                           Sample Details                                                                                                              Service Requested: (Please Tick)
                                               Sample Code:                                                                                                                                         1-Low Resolution
                                               Sample Nature (Polar/Non Polar):                                                                                                                                 EI                            CI (+ve ion)                             CI (-ve ion)
                                               Mass Range/Mol. Mass:                                                                                                                                            GC/MS  FAB (+ve ion)  FAB (-ve ion)
                                                                                                                                                                                                               (Required GC)
                                               M.P / B.P:                                                                                                                                           2-High Resolution
                                               Solubility:                                                                                                                                          (Please attach a copy of Low Resolution Spectrum)
                                               Sample Amount (not more than 1.0 mg)                                                                                                                             EI         FAB (+ve ion)                                               FAB (-ve ion)
                                               Other Details:                                                                                                                                       Elements O, S, N, Cl, F, I, Br                                                      Others:               
                                                                                                                                                                                                    Max. no of Elements:                                                
                                                                                                                                                                                                    Expected Mass:                                                         
                                                                                                                                                                                                    Expected Formula:                                                    
                                                
                                           For Lab Use Only:
                                           Analysis Complete Date:                                                                                                                              
                                           Signature of Analyst:                                                                                                                                                     
                                           Status:                                    OK                                       NOT OK
                                                                                                                                                                                                                                        Prof. Dr. Khalid M. Khan, T.I.
                                                                                                                                                                                                                                     Incharge Mass Spectrometry facilities
                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                            Date: 
                                                                                                                                                                         ___________________________
                                                                                  For Any Query please contact: HEJ Mass Lab # 104 & 102 / Intercom # 104 & 103