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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.