Restek-TN Applications_344 - page 275

CLINICAL/FORENSICS
64
www.restek.com
Custom Reference Materials Request Form
Take these eight steps tocreate the rightsolution:
1. MixtureDescription: ________________________________________________________________________________
2. Solvent: __________________________________________________________________________________________
3. Number of Components: ________
4. Volumeper ampul (select): 1mL, 2mL, 5mL, 10mLor other ______mL
5. Quantityof ampuls: ________
6. Testinganddocumentation that bestmeets your requirements:
❍ GravimetricDocumentation: Lot Sheetwithbalanceprintout attached.
❍ QualitativeDocumentation: Certificateof Composition, Chromatogram, andGravimetricDocumentation.
❍ QuantitativeDocumentation: Certificateof Analysis andDataPack.
7. Compound(s): (list or attach sheet; includeCASnumber)
Compound01: ______________________________________________________________ Concentration: ____________________
Compound02: ______________________________________________________________ Concentration: ____________________
Compound03: ______________________________________________________________ Concentration: ____________________
Compound04: ______________________________________________________________ Concentration: ____________________
Compound05: ______________________________________________________________ Concentration: ____________________
Compound06: ______________________________________________________________ Concentration: ____________________
Compound07: ______________________________________________________________ Concentration: ____________________
Compound08: ______________________________________________________________ Concentration: ____________________
Compound09: ______________________________________________________________ Concentration: ____________________
Compound10: ______________________________________________________________ Concentration: ____________________
Compound11: ______________________________________________________________ Concentration: ____________________
Compound12: ______________________________________________________________ Concentration: ____________________
Compound13: ______________________________________________________________ Concentration: ____________________
Compound14: ______________________________________________________________ Concentration: ____________________
Compound15: ______________________________________________________________ Concentration: ____________________
Compound16: ______________________________________________________________ Concentration: ____________________
Compound17: ______________________________________________________________ Concentration: ____________________
Compound18: ______________________________________________________________ Concentration: ____________________
Compound19: ______________________________________________________________ Concentration: ____________________
Compound20: ______________________________________________________________ Concentration: ____________________
8. ConcentrationUnits
❍ mg/mL ❍ μg/mL ❍ ng/mL ❍ vol./wt.% ❍ wt./wt.% ❍ other______________________
Contact Information:
Name: ____________________________________________________________ Date: ______________________
Company/Location: __________________________________________________________________________________
____________________________________________________________________________________________________
Phone#:__________________________________________ FAX#:__________________________________________
E-mail: ______________________________________________________________________________________________
U.S. Customers
FAX#: (814) 355-2895
email: standards@restekcorp.com
online form: www.restek.com
International Customers
ContactYour
RestekRepresentative.
ALLmixtures are produced in accordancewith our ISO 9001:2000 registration.
Analytical balances are calibrated daily at sevenmass levels usingNIST traceableweights.
ALL rawmaterials used are aminimum of 97% pure unless otherwise specified.