Mass Spec Sample Submission Form

MASS SPEC SAMPLE SUBMISSION FORM Call UMESH (850) 644-1697 Please Fill out Completely AND SIGN AT THE BOTTOM

Name: _ Date: Phone: email: Professor: Sample Name:

Resolution: Low High

Inlet Method (if EI/CI): Direct Inlet (Standard). If in solution: Solvent & Conc. (mg/mL) GC Inlet If GC, please attach GC trace and conditions and give Sample concentration and solvent:

Ionization Method: (Please circle one) EI CI+ ESI+ Soluble in MeOH/ACN/H2O ? CI- ESI- Soluble in MeOH/ACN/H2O ? FAB+ FAB-

Molecular Formula (if known) & Structural formula:

Estimated Molecular Weight: (If GC, List in order of elution)

Mass Range to Scan:

Sample: Origin:

Likely Impurities:

Last Purification Technique:

% Purity: Special Instructions (handling, storage, etc.): I certify that this sample is submitted for research purposes only.

Signature: Date: