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MASS SPECTROMETRY REQUEST FORM
IMSERC, DEPARTMENT OF CHEMISTRY
NORTHWESTERN UNIVERSITY
USER INFORMATION
User Name: First________________Last________________
Sample Code: ______________ Date:______________
Advisor: ___________________ Acct. No: ___________________________
Phone No: ___________________
Campus Address:______________________________________________________________________________
Preffered Data Return (email / paper):_______________________________________________________________
Email Address:_____________________________________
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SAMPLE INFORMATION
Molecular Weight:
________________________________
Molecular Formula
: ________________________________
Purity: __________
Concentration (Solution): ____________
Contaminants (Salt/buffer/starting
material):
_______________________________________________
M/B Point (For EI):
________________________________
Recommended Solvent:
_____________________________
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Sample Structure
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Source:
__ Synthetic
__ Commercial __ Natural __ Derivative
or Metabolite __ Other _____________________
Stability:
__ Stable __ Thermal
Labile __ Water Sensitive __ Air
Sensitive __ Light Sensitive
Hazards:
__ Toxic
__ Flammable __ Corrosive __
Bad Smell __ Radioactive __ Other:_____________________
Storage: __Check if
sample in refrigerator
Sample Return:
__ Yes
__ No
(1 week to pick up)
SERVICE REQUESTED
Ionization Technique: __EI
__ESI __APCI __APPI __MALDI
Scan Range: From__________To__________
Mode: __Negative Ion __Positive Ion
Type of Data: __ Molecular
Weight __ Fragments
__ Exact
Mass __ LC/MS
(User must provide method and column)
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