University Instrumentation Center

Electron Microscope Facility

Please look over and call (603) 862-2182 to discuss your sample before completing this form.

To be filled out by client:

Name________________________________________ Date__________________

Advisor’s signature (if applicable)____________________________________________

Grant #/ Company/PO#_____________________________________________

Phone #_________________________________ Email______________________

Address (if on campus, what building?) __________________________________

Sample name_____________________________ Sample composition______________

Service(s) Requested:

SEM ____________________ EDS __________________ TEM __________________

Sectioning: thin (grids) __________ thick (slides)__________ cryo __________

Cu Grids: mesh size __________ coated or uncoated__________

Special Sample Handling Instructions (help us help you!):

If requesting SEM or EDS, is sample conductive? Yes _____ No _____

If not conductive, what type of coating is requested? Au __ Au/Pd __ Pt __ Carbon ___

What magnifications are requested? __________________

What views are of interest? __________________

What information are you hoping to obtain from this sample?

Special Instructions:

Disclaimer:

Quoted charges are only approximations based on accepted sample preparation protocols and instrument procedures. Actual charges may vary when additional work is required (on samples) because further preparations are needed/required or because the results/data produced initially may not have been adequate/appropriate/conclusive, even though procedures were properly followed and the instruments were working correctly.

Additional work may involve additional charges. If charges exceed the original estimate, work will not proceed unless approved in advance by telephone or e-mail.

I have read and agreed to the terms outlined in this form.

Authorized Signature Date

To be filled out by EMF:

Date completed __________________

Comments: