NANO-SciTech CentreInstitute of ScienceLevel 3, Block CUniversiti Teknologi MARA40450 Shah AlamSelangor

Tel: 03 5544 4415/4412 Fax: 03 5544 3870Email: salifairus@salam.uitm.edu.my nurulwahida@salam.uitm.edu.my mohdazlan602@salam.uitm.edu.my

Application Status:

TOTAL CHARGE (RM) :

Signature :

Signature :

Approve Not Approve 1. Please submit the completed application form to NANO-SciTech Centre.2. Please contact NANO-SciTech Centre pertaining to the approval of the application.3. Please make sure that the workplace is in good condition before you leave the laboratories..4. Any damages or accidents must be reported immediately to the authority officer.5. Maximum of 3 samples only are allowed for each application.6. Please use CD to copy you data from the computer. Any USB drivers are not allowed to be used.

PART D : FOR OFFICE USE ONLY PART E : TERMS & CONDITIONS

PART B : SAMPLE INFORMATION

PART A : APPLICANT’S INFORMATION

APPLICATION FORM

Applicant’s Name :

Staff/Student No :

Telephone No. :

Programme Code :

E-mail :

Supervisor’s Name :

Email :

Applicant’s Signature : Supervisor’s Signature :

Billing Address :

Date :

Date Completed :

Additional Info :

We hereby certify that all information provided in this application are true. We also agree and understand that any damaged to the machine due to any falsification of this information will be our responsibility.

PART C : DECLARATION

UiTM : RM 50.00 / Sample Non UiTM : RM 150.00 / Sample

PARTICALSIZER

Grant No. :

No. SampleID

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