Page 1 of 5 BORANG PERMOHONAN PERKHIDMATAN ANALISIS
ANALYSIS SERVICES APPLICATION FORM Pusat Instrumentasi dan Perkhidmatan Sains
Tel.: 088-320 000 Samb. 203900 E-mel: labservices_pips@ums.edu.my No. Rujukan: UMS/PIPS1.3.4/800-1/1/2 (Ver. 1/2021) _______ /_________ / _________
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 labservices_pips@ums.edu.my/Complete form can be sent to labservices_pips@ums.edu.my
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) Harga /Price (RM) Bil. Sampel/ No. of Samples Bil. Hari/ No. of Days No. of Softcopy (CD) Harga/ Price (RM) 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/ Grand Total (RM) * Sila rujuk lampiran untuk senarai harga/
Page 2 of 5 2. Tunai/ Cash
3. Kaedah Pembayaran Pelbagai/ Multiple payment methods
(Rujuk lampiran kaedah pembayaran/ Please refer payment method attachment)
*
Nota/Note: Kod Akaun PIPS/ PIPS Account code: PR00154
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
Pihak PIPS hanya menyerahkan data analisis kepada pemohon atau / dan penyelia untuk melindungi data pemohon.
Penyerahan Data Analisis Penerimaan Data Analisis
Nama Pegawai yang
menyerahkan data analisis Nama Penerima
Tandatangan Tandatangan
Page 3 of 5 SENARAI HARGA KOS PERKHIDMATAN ANALISIS PIPS (Lampiran/ Enclosure)
Instrumen/Instrument Kod/Code Brand/Model Parameter
(a) Caj Perkhidmatan analisis/Analysis services charge Softcopy (b) (CD) Penyelidik
UMS/ UMS Researcher
Pascasiswazah/
Postgraduate Undergraduate Prasiswazah/
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 EMITECH K550X 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 SMARTLAB RIGAKU Per Sample RM120.00 RM60.00 RM24.00 RM144.00 RM216.00 RM2.00
INDUCTIVELY COUPLED PLASMA MASS SPECTROMETRY
Page 4 of 5 government) 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
GCM 002 Per sample (Chemical
Ionization) RM200.00 RM100.00 RM40.00 RM250.00 RM300.00 RM2.00
GCM003 (Additional Per sample
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 MACRO CUBE VARIO 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 ANALYZER™ FRAGMENT
Page 5 of 5 SENARAI HARGA KOS PERKHIDMATAN ANALISIS PIPS (Lampiran/ Enclosure)
Instrumen/Instrument Kod/Code Brand/Model Parameter
(a) Caj Perkhidmatan analisis/Analysis services charge Softcopy (b) (CD) Penyelidik
UMS/ UMS Researcher
Pascasiswazah/
Postgraduate Undergraduate Prasiswazah/
Luar UMS (Kerajaan)/ External user (government) Luar UMS (Bukan Kerajaan)/ External user (non-government) Parameter: Per Piece
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
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 N1300E EYELA 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 -
