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Chemical Analysis Pty Ltd ACN 114 804 572 110 Merrindale Drive Croydon VIC 3136 Australia T +61 3 9737 4300 E info@chemicalanalysis.com.au W chemicalanalysis.com.au
Analysis Request Form
Fields marked with a (*) are required See overleaf for general instructions for completing this form
Results to beemailed to
Standard Urgent, please specifiy: Surcharge applies
Ambient 5°C <-10°C <-70°C *Job Type / QA Requirement:
*Method Validation / Verification / Transfer:
*Sample Description *ID No. *Qty *Test / Analysis *Test Method *SpecificationNo. of sample containers submitted per sample Where applicable
*Date: _______________*Signature: ___________________________Analysis Request Form must be signed and dated to initiate testing
CUSTOMER INFORMATION
ANALYSIS REQUEST DETAILS
CA Contact:
*Company Name:
CA Quote No.: Results Required:
*Sample Storage Conditions at CA:PO No.:
Not Required
Job Number: C___ ___ ___ ___ ___ ___ ___
Condition on arrival: Satisfactory Not Satisfactory
Date & Time received: ___/ ______/ ______ : ______AM/PM Initials:_________
Sample (s) logged: ___/ ______/ ______ Initials: _________
I.e.: Sample Integrity, Documentation, Labels and Temperature (where applicable)
Temperature on arrival: Cold
CSA Type: Standard
Ambient
CHEMICAL ANALYSIS USE ONLY
Modified
Record (if temperature logger supplied and required by Customer):____ °C
Customer
Comments: ____________________________________________________________________________________________
GMP – FDA (21 CFR Part 210 and 211)
Chemical Analysis Form - FRM002, Version 10
Required Quote to be approved
GMP – TGA (PIC/S) / APVMA Others – R&D, ES, Industrial etc
No.
*Email(s):*Request Date:
Stability Storage at CA Please provide Stability Protocol/ additional instructions
*Sample Hazardous: Yes No (If Yes, MSDS must be supplied)
Previously Validated / Verified / Transferred
Additional Information – Please provide special instructions e.g. sample composite requirement, stability storage conditions, reference to additional protocol/ instructions etc. and attach as required:
CSA within expiry date: Yes No
*Phone Number:*Requestor:
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Chemical Analysis Pty Ltd ACN 114 804 572 110 Merrindale Drive Croydon VIC 3136 Australia T +61 3 9737 4300 E info@chemicalanalysis.com.au W chemicalanalysis.com.au
INSTRUCTIONS TO CUSTOMERS 1. Please ensure paperwork submitted matches samples prior to submission to CA.2. Separate samples should be submitted for Chemistry and Microbiology testing (where possible).3. Please select the applicable regulatory requirements for the Job Request under Job Type / QA Requirement.4. This form can be used to refer to additional customer in-house request forms, protocols, and instructions.5. If more samples are to be submitted, additional Analysis Request Forms can be completed and attached.6. Samples will be retained for 4 weeks after approval of the final report and then disposed of appropriately
unless otherwise requested.
Chemical Analysis Form - FRM002, Version 10
No. of sample containers submitted per sample Where applicable No.
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