Service requisition form

Job No.:

Centralized Analytical Laboratory (CAL)

Block P, Ground Floor
Universal Testing Machine (UTM)
(Location : 13-00-01, 17-)
Name :_________________________________________________ Company Name: …………………………………………………….

ID No :______________Contact No:__________________________ Address: ………………..……………………………………………….

Status :□ FYP □ MSc □ PhD □ RO □Others:_________________ ………………………………….. ………………………………………….

Department :□ME □ EE □CHE □CV □GPE □FASD □Others: _____

Covenant of Applicant.
Project title :__________________________________________________
I ………………………. Have read and fully understood
Cost Center :_________________________________________________ and agreed to abide by the “General Information,
Terms and Conditions Relating to Acceptance of
Supervisor :_________________________________________________ Projects for Testing and Laboratory Rules and
Regulation”.
E-mail :__________________________________________________
Signature :……………………………………
Analysis : □Tensile □Bending □Compression □Static □Fatigue
IC NO :……………………………………
Sample : □ Concrete □ Steel □Polymer □Polymer,
□ Others, Please Specify:___________________ Date :……………………………………

*To be filled by internal customer only

Sample Size (mm)
No. Sample Name Sample Weight (kg) Remarks
LXWXT

Endorsed by:

________________________
(Supervisor/Project Leader)

FOR DEPARTMENT/CENTRE/SECTION USE:

Services applied can/cannot be provided. Proposed date of Testing :
Signature:
Name:
Designation:
Date:

Result & Sample Collected By:

Signature:
Name:
Date:

Customer Feedback form : □ Yes □ No

Note:
Please label your samples properly.
Person in-charge: Mr Johan Ariff, Email: johanariff_a@utp.edu.my Tel: 05-3687334 Page 1 of 3
Results can be collected using a blank cd-r only.