(PRC‐JUST)  Jordan University of Science and Technology (JUST) Pharmaceutical Research Center (PRC)

1.Client Details:

Name: Research No.

Address:

Contact: Phone: Fax:

E-mail: Company:

Additional Info. :

2.Analysis request details.

No. of samples: Samples Hazardous (If yes, MSDS must be supplied)

Yes No

Recommended Sample Storage: Room Temp. 4˚C -20˚C other_____

The samples should Return to the client. Yes No (samples will stored Only

3 months)

# Sample Identification:(eg. Lot Number, Date)

PRC-JUST Sample Code

Sample Description and/or required analysis

1

2

3

4

5

Notes________________________________________________________________________

_______________________________________________________________________. 

Client Name & Signature: PRC-JUST Director & signature: