University of Alberta  
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Analysis Request Form

University: Department:

Staff Member requesting analyses Title:
(students give the name of the supervisor)

Mailing address:

Telephone number: Facsimile number:

Electronic mail address:

Invoicing Department:

Your purchase order number:
Results will not be released until purchase order number is received

I have read and agreed with the ACSES academic usage agreement (see below):

Yes No

Requested analysis is for academic use only and should be charged at academic rates



Turnaround requested: Normal
(Results generally within 14
days of sample receipt)
72 hour
50% Surcharge
(minimum verbal report within
three business days of sample receipt)
24 hour
100% Surcharge
(minimum verbal report within
one business day of sample receipt)

Describe the problem:

Analyses required (if known):

Sample description:

Discard sample(s) after analyses?: Yes No
Return sample(s) after analyses: Yes

Report format: Hard Copy Facsimile Electronic Mail
  Floppy Disk *
*$1.00 CAD will be added to invoice
Compact Disk *
*$2.00 CAD will be added to invoice
Sample submission guidelines: 1. Samples and area(s) of analysis should be clearly marked and labeled

2. Samples should be clean (i.e. free of finger prints, dirt, debris), and wrapped separately

3. A surcharge of $25.00 CAD will be levied when obvious dangerous/hazardous goods arrive in our facility without the appropriate Dangerous Goods Declaration and MSDS

Contact person: E-mail: Phone: Date:

Academic Usage Agreement for ACSES

1. Academic users are defined as faculty members holding at least a 0.5 FTE paid position at a Canadian university.

2. Academic users must agree to the following principles and undertakings as a condition for access to the equipment:

(a) Academic use of the facility implies free exchange of data and eventual publication of results. Confidential testing of samples is to be charged at the proper non-academic rate in all cases.

(b) Users of ACSES acknowledge the use of the facility in all publications and reports.

(c) Copies of papers and reports that incorporate data from the instruments are provided to ACSES for reporting and record keeping.