1-2 SAMPLE ANALYSIS QUESTIONNAIRE This form is to be completed by the client before a sample can be processed. Please attach MSDS for all components or for mixture to this request form. Company Department Date Name Phone Address Fax e-mail >> Please provide a detailed description of the purpose for this analysis (use additional sheets if necessary): >> Sample description: >> Present means of analysis, including Melt Flow Rate/Model # of instrument used: >> Expected Particle Size (µm) smallest: largest: mean: Dispersion fluid to be used: Surfactant to be used: Approximate sample concentration: Recommended sample preparation: Your distributor for Fluid Imaging Technologies in Germany, Luxembourg, Austria and Switzerland ANASYSTA e.K. Lipperheidstraße 75 46047 Oberhausen Germany Phone +49-(0)208-82 419-40 Fax +49-(0)208-82 419-50 eMail [email protected] www.anasysta.com 2-2 Storage conditions: Preservation method: >> What results are you seeking (e.g. particle size, shape, count, etc.)? >> Is there anything else we should know about the sample (e.g. hazardous, special storage or processing conditions)? Please attach MSDS’s if applicable. Fluid Imaging Technologies reserves the right to return any sample once processed. Include this form when mailing your samples to the address below. Thank you for your interest in FlowCAM® Your distributor for Fluid Imaging Technologies in Germany, Luxembourg, Austria and Switzerland ANASYSTA e.K. Lipperheidstraße 75 46047 Oberhausen Germany Phone +49-(0)208-82 419-40 Fax +49-(0)208-82 419-50 eMail [email protected] www.anasysta.com