Tarikh kemaskini borang: 11 Mei 2022
BORANG PERMOHONAN PERKHIDMATAN ANALISIS ANALYSIS SERVICES APPLICATION FORM
Pusat Instrumentasi dan Perkhidmatan Sains
No. Rujukan:
UMS/PIPS1.3.4/800-1/1/2 (Ver. 2/2022)
Tel.: 088-320 000 Samb. 203900 / /
E-mel: labservices_pips@ums.edu.my
1. Si la berunding dengan pegawai terlebih dahulu sebelum melengkapkan Borang Permohonan/Please consult with officer first before fill in the Request Form
2. Si la lengkapkan Borang Permohonan untuk s ebut harga (bagi pengguna luar UMS s ahaja)/Please fill in Request Form for quotation (for external user only)
3. Bora ng ya ng telah l engkap diisi boleh dihantar ke labservi ces_pips@ums.edu.my/Complete form can be sent to l a bservi ces_pips@ums.edu.my
4. Si la 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. Na ma /Name 2. Ja wa tan/Position
3. No. K.P/No. Per/No. Ma trik I.C No./Per No./Matric No.
4. Fa kulti/Jabatan/Agensi/Program Faculty/Department/Agency/
Programme
5. No. Tel . (Peja ba t/HP) Tel. No. (Office/HP)
6. E-mel /E-mail 7. Ta ri kh Analisis diperlukan/
Requested Date of Analysis 8. Na ma Penyelia (Jika Pelajar)/
Supervisor Name (If Student) 9. Ta juk Projek Penyelidikan/ Kod
Projek/Research Project Title/Project Code
10. Ka tegori Pengguna [Sila tandakan (√)]/Applicant’s Category [Please remark (√)]
UMS Buka n UMS/Non-UMS
Penyelidik/Researcher Kera ja an/Government
Pel a jar Pa scasiswazah/Postgraduate Student Buka n Kerajaan/Non-Government Pel a jar Pra siswazah/Undergraduate Student
Maklumat Ujian/Testing Information Ketera ngan sampel (contoh: daun/tanah/seramik/dll, sertakan
l a mpiran ji ka perlu)/sample information (example:
leaf/soil/ceramic/etc., attach attachment if necessary)
Kod/Code
Si l a isi mengikut paramater berka i ta n s a ha ja (Rujuk l a mpi ra n)/
Please fill in relevant parameters only
(Refer to attachment) Kod/Code
Si l a isi mengikut paramater berka i ta n s a ha ja (Rujuk l a mpi ra n)/
Please fill in relevant parameters only (Refer to attachment) Bi l .
Sa mpel / No. of Samples
Bi l . Hari/
No. of Days
No. of Softcopy (CD)
Ha rga /Price
(RM)
Bi l . Sa mpel/
No. of Samples
Bi l . Hari/
No. of Days
No. of Softcopy (CD)
Ha rga / 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 GRI 001
Jumlah keseluruhan/ Grand Total (RM)
* Si la rujuk l ampiran untuk s enarai ha rga/
Please refer attachment for price list
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Tarikh kemaskini borang: 11 Mei 2022
Kaedah Bayaran/ Payment Method
Sila tandakan (√)/ Please remark (√)
1. Gera n Penyelidikan/ Research grants
2. Tuna i/ Cash
3. Ka eda h 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
_____ _
Ta ndatangan/Signature Ta ri kh/Date
BAHAGIAN II: PERAKUAN KETUA JABATAN PEMOHON /KETU A PROJEK/PENYELIA/ A CKN OW LED GME NT OF DEPARTM ENT HEAD/PROJECT LEADER/SUPERVISOR
Sa ya bersetuju/tidak bersetuju membiayai kos perkhidmatan tersebut/
I agree/disagree with the service cost Sumber Peruntukan/Sourceof Allocation:
Ul a san/Comments:_____________________________________________________________________________________________________
________________________________
Ta ndatangan/Signature Ta ri kh/Date
BAHAGIAN III : KELULUSAN PUSAT INSTRUMENTASI DAN PERKHIDMATAN SAINS/APPROVAL FROM CENTRE OF INSTRUMENTATIONS AND SCIENCE SERVICES DEPARTMENT
Di l uluskan/Tidak diluluskan/Approved/Not Approved:
Ul a san/Catatan/Remarks:
Ta ndatangan/Signature Ta ri kh/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
Tarikh Tarikh
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Tarikh kemaskini borang: 11 Mei 2022
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 (govern m ent)
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
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
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Tarikh kemaskini borang: 11 Mei 2022
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 (govern m ent)
Luar UMS (Bukan Kerajaan)/
External user (non- government)
Parameter:
Per Piece
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
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 RM30.00 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
*To calculate:
[No. of elements]
x [No. of samples] x Charge
RM15.00 RM10.00 RM10.00 RM20.00 RM30.00 RM2.00
AAS 002
Per Sample (If no. of elements
>5 per- sample)
RM60.00 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 Page 4 of 5
Tarikh kemaskini borang: 11 Mei 2022 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 (govern m ent)
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 RM20.00 RM10.00 RM4.00 RM24.00 RM36.00 RM2.00 PROTEIN ANALYZER PRO 001
GERHARDT Per Sample RM150.00 RM75.00 RM30.00 RM180.00 RM270.00 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 -
GRINDER GRI 001 IKA MF10 Per Day RM10.00 RM5.00 RM2.00 RM12.00 RM18.00 -
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