Mass Spectrometry Request	________________

Contact Information

Name:	_____________________________	Group:	_____________________________

Email:	_____________________________	Institution:	_____________________________

Phone:	_____________________________

Requested Methods

Ionization1:	MS-Mode:
☐ ESI	☐ mass (± 0.1 Da)
☐ FD	☐ acc. mass (± 0.005 Da), ESI only!

Sample Information:

Sample ID: ________________ Sum formula: ________________ monoisotopic mass (M): ________________ if dissolved, solvent and conc. (mmol/L): ________________ Solvents ESI only ESI/FD FD only ☐ H2O ☐ MeOH ☐ CHCl3 ☐ CH3CN ☐ CH2Cl2, ☐ DMSO If not applicable, other: ________________	Molecular structure Click on this field but not the central symbol to paste from clipboard!
Sample purification: ☐ HPLC ☐ LC ☐ Distillation ☐ Crystal/Precipitation ☐ none Sample return requested: ☐ yes ☐ no	for acc. mass only: ESI(+): [M+H]+ ________________ [M+Na]+ ________________ ESI(–): [M-H]- ________________

Comments and remarks:

Please hand in dangerous or instable samples personally!

______________	_________________________

Date	Signature