CIL, CUPB SERVICE REQUEST FORM
Name & Address of the Organisation *
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Phone
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Fax
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Email *
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Website
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Name of the Contact Person *
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Mobile Number of the Contact Person *
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Date of Depositing the Sample
MM
/
DD
/
YYYY
Time of Depositing the Sample
Time
:
Name / Nature of the Sample
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No. of the Sample (if more than one for same kind)
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Customer’s Code (If any)
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Brand Name (If any)
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Batch No. & Date of Manufacture (If any)
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Test Parameter 1 *
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Testing Charges of Test Parameter 1 *
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Test Parameters 2
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Testing Charges of Test Parameter 2
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Test Parameters 3
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Testing Charges of Test Parameter 3
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Test Method Specified by Customer (If any)
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Purpose of Testing
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Declared value (if any)
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Specific Storage Conditions (Please tick the appropriate box)
Column 1
Room Temperature
Refrigerated (4 ± 2 oC)
Deep Freezer (- 18 ± 2 oC)
Mode of payment
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Receipt No.
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Testing as per Specification (if required)
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Estimated due date (For Official Use)
MM
/
DD
/
YYYY
Any other
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