BORANG PERMOHONAN PERKHIDMATAN ANALISIS No ......Softcopy (CD) Bil. Sampel/ No. of Samples Bil....

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BORANG PERMOHONAN PERKHIDMATAN ANALISIS ANALYSIS SERVICES APPLICATION FORM

Pusat Instrumentasi dan Perkhidmatan Sains Tel.: 088-320 000 Samb. 203900

E-mel: [email protected]

No. Rujukan: UMS/PIPS1.3.4/800-1/1/2 (Ver. 2/2020) _______ /_________ / _________

1. Sila berunding dengan pegawai terlebih dahulu sebelum melengkapkan Borang Permohonan/Please consult with officer first before fill in the Request Form

2. Sila lengkapkan Borang Permohonan untuk sebut harga (bagi pengguna luar UMS sahaja)/Please fill in Request Form for quotation (for external user only)

3. Borang yang telah lengkap diisi boleh dihantar ke [email protected]/Complete form can be sent to [email protected]

4. Sila bawa salinan Borang Permohonan dan bukti pembayaran untuk rujukan pegawai/Please bring a copy of Request Form and payment proof for officer as Reference

BAHAGIAN I : BUTIRAN PERMOHONAN/APPLICANT’S INFORMATION

1. Nama/Name

2. Jawatan/Position

3. No. K.P/No. Per/No. Matrik I.C No./Per No./Matric No.

4. Fakulti/Jabatan/Agensi/Program Faculty/Department/Agency/ Programme

5. No. Tel. (Pejabat/HP) Tel. No. (Office/HP)

6. E-mel/E-mail

7. Tarikh Analisis diperlukan/ Requested Date of Analysis

8. Nama Penyelia (Jika Pelajar)/ Supervisor Name (If Student)

9. Tajuk Projek Penyelidikan/ Kod Projek/Research Project Title/Project Code

10. Kategori Pengguna [Sila tandakan (√)]/Applicant’s Category [Please remark (√)]

UMS

Bukan UMS/Non-UMS Penyelidik/Researcher Kerajaan/Government Pelajar Pascasiswazah/Postgraduate Student Bukan Kerajaan/Non-Government Pelajar Prasiswazah/Undergraduate Student

Maklumat Ujian/Testing Information

Keterangan sampel (contoh: daun/tanah/seramik/dll, sertakan lampiran jika perlu)/sample information (example: leaf/soil/ceramic/etc., attach attachment if necessary)

Kod/Code

Sila isi mengikut paramater berkaitan sahaja (Rujuk lampiran)/

Please fill in relevant parameters only (Refer to attachment)

Kod/Code

Sila isi mengikut paramater berkaitan sahaja (Rujuk lampiran)/

Please fill in relevant parameters only (Refer to attachment)

Bil. Sampel/ No. of

Samples

Bil. Hari/No. of Days

No. of Softcopy

(CD)

Bil. Sampel/ No. of

Samples

Bil. Hari/ No. of days

No. of Softcopy (CD)

FES 001 AAS 001

FES 002 AAS 002

SEM 001 FRA 001

FTI 001 BIO 001

AFM 001 BIO 002

XRD 001 VIS 001

ICP 001 FAT 001

SPU 001 PRO 001

GCM 001 FRE 001

GCM 002 FIB 001

GCM003 ROT 001

HPL001 CO2 001

TOC 001 LNG 001

CHN 001

Jumlah keseluruhan/Total (RM) * Sila rujuk lampiran untuk senarai harga/ Please refer attachment for price list

mailto:[email protected]

mailto:[email protected]

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Kaedah Bayaran/ Payment Method

Sila tandakan (√)/ Please remark (√)

1. Geran Penyelidikan/ Research grants

2. Tunai/ Cash

3. Kaedah Pembayaran Pelbagai/ Multiple payment methods (Rujuk lampiran kaedah pembayaran/ Please refer payment method attachment)

Tandatangan Pemohon/Applicant Signature

______________________________

Tandatangan/Signature

___________________________

Tarikh/Date

BAHAGIAN II: PERAKUAN KETUA JABATAN PEMOHON/KETUA PROJEK/PENYELIA/ACKNOWLEDGMENT OF DEPARTMENT HEAD/PROJECT LEADER/SUPERVISOR

Saya bersetuju/tidak bersetuju membiayai kos perkhidmatan tersebut/ I agree/disagree with the service cost Sumber Peruntukan/Source of Allocation: ___________________________________________________________________________________________________________

Ulasan/Comments:_____________________________________________________________________________________________________________________________________

______________________________ Tandatangan/Signature

___________________________ Tarikh/Date

BAHAGIAN III : KELULUSAN PUSAT INSTRUMENTASI DAN PERKHIDMATAN SAINS/APPROVAL FROM CENTRE OF INSTRUMENTATIONS AND SCIENCE SERVICES DEPARTMENT

Diluluskan/Tidak diluluskan/Approved/Not Approved:____________________________________________________________________________________________

Ulasan/Catatan/Remarks: _____________________________________________________________________________________________________________________________

______________________________

Tandatangan/Signature

___________________________ Tarikh/Date

Kegunaan Pusat Instrumentasi dan Perkhidmatan Sains

Tarikh Borang Diterima (Borang yang telah lengkap diisi bersama bukti bayaran)

Nama & Tandatangan Penerima Borang

Tarikh pemakluman jadual perkhidmatan analisis kepada pemohon

Perakuan Kakitangan PIPS (Nama & Tandatangan )

Pengesahan Pemohon (Nama & Tandatangan)

Tarikh sampel diterima Nama & Tandatangan Penerima Sampel

Jumlah bayaran diterima (RM) No. Resit /Tarikh

Perakuan Penerimaan dan Penyerahan Data Analisis

Penyerahan Data Analisis Penerimaan Data Analisis

Nama Nama

Tandatangan Tandatangan

Tarikh Tarikh

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SENARAI HARGA KOS PERKHIDMATAN ANALISIS PIPS (Lampiran/ Enclosure)

Instrumen/Instrument Kod/Code Brand/Model Parameter

(a) Caj Perkhidmatan analisis/Analysis services charge (b)

Softcopy (CD)

Penyelidik UMS/ UMS Researcher

Pascasiswazah/ Postgraduate

Prasiswazah/ Undergraduate

Luar UMS (Kerajaan)/

External user (government)

Luar UMS (Bukan

Kerajaan)/ External user

(non-government)

Parameter: Per Piece

FIELD EMISSION SCANNING ELECTRON MICROSCOPE (please add for SPUTTER COATER* if sample is biological/non-conductive material)

FES 001 JEOL JSM-

7900F Per Sample RM250.00 RM125.00 RM50.00 RM300.00 RM450.00 RM2.00

FIELD EMISSION SCANNING ELECTRON MICROSCOPE WITH EDX (please add for SPUTTER COATER* if sample is biological/non-conductive material)

FES 002 JEOL JSM-

7900F Per Sample RM300.00 RM150.00 RM60.00 RM360.00 RM540.00 RM2.00

SCANNING ELECTRON MICROSCOPE (please add for SPUTTER COATER* if sample is biological/non-conductive material)

SEM 001 CARL ZEISS

MA 10 Per sample RM60.00 RM30.00 RM10.00 RM100.00 RM150.00 RM2.00

SPUTTER COATER* SPU 001 K550X

EMITECH Per sample RM10.00 RM10.00 RM10.00 RM20.00 RM40.00 RM2.00

FOURIER TRANSFORM INFRA-RED 2D

FTI 001 PERKIN ELMER

FRONTIER Per sample RM60.00 RM30.00 RM12.00 RM72.00 RM96.00 RM2.00

ATOMIC FORCE MICROSCOPE AFM 001

BRUKER DIMENSION ICON SCAN

ASSYST

Per sample RM160.00 RM80.00 RM32.00 RM192.00 RM288.00 RM2.00

X-RAY DIFFRACTOMETER (XRD)

XRD 001 RIGAKU

SMARTLAB Per Sample RM120.00 RM60.00 RM24.00 RM144.00 RM216.00 RM2.00

INDUCTIVELY COUPLED PLASMA MASS SPECTROMETRY (ICP-MS)

ICP 001 NEXION 200 Per Sample RM300.00 RM150.00 RM60.00 RM360.00 RM600.00 RM2.00

GAS CHROMATOGRAPHY-MASS SPECTROMETRY (GC-MS)

GCM 001 AGILENT

5975C

Per sample (Electron

Ionization) RM100.00 RM50.00 RM20.00 RM200.00 RM300.00 RM2.00

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Softcopy (CD)






Luar UMS (Bukan


(non-government)


GCM 002 Per sample (Chemical Ionization)

RM200.00 RM100.00 RM40.00 RM250.00 RM300.00 RM2.00

GCM003 Per sample (Additional

Charges) RM30.00 RM30.00 RM30.00 RM36.00 Rm60.00 RM2.00

HIGH PERFORMANCE LIQUID CHROMATOGRAPHY (SEMI-PREP)

HPL001 SHIMADZU LC-6AD

Per sample RM25.00 RM25.00 RM10.00 RM75.00 RM150.00 RM2.00

TOTAL ORGANIC CARBON TOC 001 ELEMENTAR

VARIO Per sample RM50.00 RM25.00 RM10.00 RM60.00 RM90.00 RM2.00

CHNS ELEMENTAR ANALYZER CHN 001 VARIO

MACRO CUBE Per sample RM80.00 RM40.00 RM40.00 RM100.00 RM200.00 RM2.00

ATOMIC ABSORPTION SPECTROMETER

AAS 001 PERKIN ELMER

PINAACLE 900

Per Element/Per

Sample (No. of

sample 1-5)

RM10.00 RM10.00 RM10.00 RM20.00 RM30.00 RM2.00

AAS 002

Per Element/Per Sample (No.

of sample >5)

RM50.00 RM50.00 RM50.00 RM120.00 R150.00 RM2.00

FRAGMENT ANALYZER FRA 001 FRAGMENT ANALYZER™

SYSTEM Per Sample RM125.00 RM30.00 RM25.00 RM150.00 RM250.00 RM2.00

BIOREACTOR 3L BIO 001 MINIFORS 2 Per Day RM100.00 RM50.00 RM20.00 RM120.00 RM180.00 RM2.00

BIOREACTOR 10L BIO 002 LABFORS 5 Per Day RM250.00 RM125.00 RM50.00 RM300.00 RM450.00 RM2.00

ULTRAVIOLET VISIBLE SPECTROPHOTOMETRY

VIS 001 AGILENT CARY 60

Per Day RM40.00 RM20.00 RM5.00 RM48.00 RM72.00 RM2.00

FAT EXTRACTION SYSTEM FAT 001 GERHARDT Per samples RM150.00 RM75.00 RM30.00 RM180.00 RM270.00 RM2.00

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Softcopy (CD)






Luar UMS (Bukan


(non-government)


PROTEIN ANALYZER PRO 001 GERHARDT

Per 8 Tubes of Samples

RM20.00 RM10.00 RM4.00 RM24.00 RM36.00 RM2.00

FREEZE DRYER FRE 001 LABCONCO Per Day RM25.00 RM12.50 RM5.00 RM30.00 RM50.00 -

FIBRE ANALYZER FIB 001 GERHARDT

Per 12 Tubes of Samples

RM25.00 RM12.50 RM5.00 RM30.00 RM45.00 RM2.00

ROTARY EVAPORATOR ROT 001 EYELA

N1300E Per Samples RM60.00 RM30.00 RM12.00 RM72.00 RM108.00 -

CO2 INCUBATOR CO2 001 ESCO Per Day RM50.00 RM25.00 RM10.00 RM60.00 RM90.00 -

LIQUID NITROGEN GAS LNG 001 IMT Per Litres RM10.00 RM5.00 RM3.00 RM12.00 RM14.00 -

BORANG PERMOHONAN PERKHIDMATAN ANALISIS No ......Softcopy (CD) Bil. Sampel/ No. of Samples Bil....

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