Contact:
(203) 744-5905
NMR Service Request Form PDF Version
Sample Information:
Submission Date:__________________ Requested Completion Date:________________
Sample identification: ____________________________________________________________________
Sample Name: __________________________________________________________________________
Number of Samples: _______ Sample weight in milligrams: _______ Sample purity: Pure_____ Mixture______
Description of Mixture ____________________________________________________________________
Solubility Information ____________________________________________________________________
Hazardous Sample Precautions_______________________________________________________________
Sample stability: Stable____ Unstable
____
Type of Precautions:
______________________________________________________________________
Please Include MSDS for all materials.
International Samples please provide TSCA Information. Please note that any costs associated with customs agents or post customs clearance shipping will be billed to the sender.
Samples will be returned to the address from which they were shipped unless directed otherwise. Further charges apply to HazMat return shipments
Return to sender _____
Return to other address
____________________________________________________________________
On a seperate sheet please draw a molecular structure of the sample and the reaction process by which the sample was prepared. This information will be treated in the strictest confidence.
If a secrecy agreement is required please fill in the following:
Secrecy Agreement Request: ________________________________________________________________
Legal Contact Information: __________________________________________________________________
_______________________________________________________________________________________
Experimental Information:
NMR Experiments to be performed: _________________________________________________________
Experimental Conditions (if known): _________________________________________________________
Technical Journal References if available: ____________________________________________________
Expectation of Results to be obtained ________________________________________________________
Results are to be returned by : e-mail_____ FAX____ Airborne _____
US mail (1st class)____ US mail (Priority)____ FedEx____
Format of e-mailed reports (circle) : Powerpoint JPEG CorelDraw Word
Raw Spectral Data Files to be provided to requestor (Circle) : Yes No
Express Service Request - Time Frame Desired ______________________________
Requestor Information:
Company:________________________________________________________________________
Street:__________________________________________________________________________
City:___________________________ State: ____ Zip ________
Requestors phone number: _____________________
Requestors FAX number: ______________________
Requestors e-mail: ___________________________
Purchase order number: _______________________
Credit Card Payment Information : Card Type (MC/Visa/Amex) ____________________________
Card Number _________________________________
Name as Printed on Card ______________________________
Expiration Date ____________________________________
Requestor's name: Printed________________________________________
Signature____________________________________
Accounts payable representative:___________________________________
Accounts payable phone number
____________________________________
PLEASE SHIP SAMPLES TO THE ADDRESS
BELOW:
Process NMR Associates, Attn: John Edwards
87A Sand Pit Rd, Danbury, CT 06810 U.S.A.
For more information on this topic please contact:
Manager, Process and Analytical NMR Services
Process NMR Associates LLC,
87A Sand Pit Rd
Danbury, CT 06810, USA
Tel: (203) 744-5905