Request Form for Custom-made Analytical Reagents / Standard Solution

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Compound name*

CAS Number

Purity grade*

Concentracion*

Enter details about the Compound in requested Custom-made Analytical Reagent and click the green [+] button to add as entry

Name

CAS

Purity Grade

Concentration

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Number of bottles/ampoules

Volume (ml)

Application Field (if known)

Prescription (if available)

Delivery Frequency

Delivery Quantity

Invoice Details

Company Name*

Tax.Number

Phone

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Additional Notes