KAMLA NEHRU MAHAVIDYALAYA,
SAKKARDARA SQUARE, NAGPUR

                 Sample analysis requisition form for TL Reader

I. User Information	Date: …………..

Name : ………………………………….

Designation / Roll No. & Course registered : …………………………………………………..

Department / Institution / Affiliation : …………………………………………………………..

Address for Communication : ………………………………..	…………………………..

Phone Number : ……………  E-mail Address : ……………………………

Special Instruction : ……………………………………………………………………………….

Certification by (Guide & HOD ): - Certified that the user is a student of our department and the work is meant for Teaching /Experimental / Research purpose of our institution.

Signature with date & Office Seal:

II. Sample Information
Number of samples:							Sample Codes: ______________		___	
* Nature of Sample	: Inorganic / organic / powder / others (specify)		
   (Tick the appropriate ones)									
   Region of measurement for TL: 0 - 4000 C temperature. 
* Nature of the sample (solid/liquid) 
   If solid, specify whether crystalline / amorphous:
*	Whether Hygroscopic or not : 
    Specify region (from …………………………… to …………………………….)
Note : Items marked * must be completed to carry out the measurements .

FOR OFFICE USE

Requisition Number :____________________
Date Received : _______________________	Date completed :______________________
Operator : ________________ Coordinator : _____________
Details of payment received: __________________________________________________________
Acknowledgement from user: Received data on completion of experiment.

Signature :	Name : _____________________ Date : ________________