Name (print): ________________________________
E-mail: ____________________________
Lab Phone extension: ____________ Other Phone # if appropriate: ____________________
Date: ______________________________
Supervisor: __________________________________
Account #: __________________________________ (Chem project code)
Status (check one):
___ Undergraduate Student ___ Graduate Student
___ Exchange student ___ Visiting Scholar
___ Postdoc ___ Faculty/Staff
___ Other (Organization/Company Name: ____________________________________________)
Prior experience with NMR Spectrometer
___ None ___ Some ___A lot
Spectrometer used previously if applicable
___ Varian ___ Bruker ___ Others
Expected frequency of spectrometer usage
___ At least once a week
___ Once every month
___ Once every few months or longer
Faculty Approval:
Signature: ___________________________________
Date: ______________________________