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Rtx, Restek logo are trademarks of
RestekCorporation.
©Copyright 2004, RestekCorporation
Restek (U.S.):
110 Benner Circle, Bellefonte, PA 16823
800-356-1688
• 814-353-1300
fax: 814-353-1309
Restek France:
phone: 33-01-60-78-32-10
Restek GmbH:
49-06172-2797-0
Thames Restek U.K., Ltd.:
44 01494 563377
Restek Ireland:
44 28 9081 4576
Custom Reference Materials Request Form
DomesticCustomers
FAX#:
(814) 355-2895
email:
ALLmixtures are produced in accordancewith our ISO 9001 registration.
Analytical balances are calibrated daily at sevenmass levels usingNIST traceableweights.
ALL rawmaterials used are aminimum of 97% pure unless otherwise specified.
International Customers
ContactYourLocal
RestekRepresentative.
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, andGravimetric
Documentation.
❍
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: ____________________________________________________________________
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