(Form-S)
ELSI laboratory equipment application form
DD/MM/YYYY
To Director of ELSI
(Academic Advisor)
Affiliation
Title
Name
(sign/stamp)
*If academic advisor does NOT belong to ELSI, please write name of ELSI faculty member as a collaborator.
Title
Name
I submit ELSI laboratory equipment application form for the following student as shown in attachment.
And, when I publish the research results, I vow to respond appropriately in consultation with relevant
parties.
Department
Student ID
number
Name
Grade
E-mail address
Phone #
(laboratory)
Emergency contact
number
Emergency contact
number of
academic advisor
Mail box # of
academic advisor
Phone # of
academic advisor
Experiment contents
Supervisor’s stamp or
signature
Equipment 1
(Room#, Supervisor)
Supervisor’s stamp or
signature
Equipment 2
(Room#, Supervisor)
Supervisor’s stamp or
signature
Equipment 3
(Room#, Supervisor)
Supervisor’s stamp or
signature
Equipment 4
(Room#, Supervisor)
Usage period
From
If you will enter on holiday and evening,
please check in □ in right column.
/
/
To
/
/
Register of admission in ELSI building
□
Remarks
If you have the disaster and accident insurance for students (GAKKENSAI) and personal liability insurance
for students-supplementary to the disaster and accident insurance for students (GAKKENBAI), please check in
□．
(Form-S)
(Attachment)
Sharing table of laboratory work
Equipment 1 (Name of equipment:
)
Sharer
Items
Purchase of running
stores and reagent1)
Apply for using
chemical closet2)
Managing of reagent3)
Managing of waste4)
Person in charge of
equipment fail5)
Equipment 2 (Name of equipment:
)
Sharer
Items
Purchase of running
stores and reagent1)
Apply for using
chemical closet2)
Managing of reagent3)
Managing of waste4)
Person in charge of
equipment fail5)
Equipment 3 (Name of equipment:
)
Sharer
Items
Purchase of running
stores and reagent1)
Apply for using
chemical closet2)
Managing of reagent3)
Managing of waste4)
Person in charge of
equipment fail5)
Equipment 4 (Name of equipment:
)
Sharer
Items
Purchase of running
stores and reagent1)
Apply for using
chemical closet2)
Managing of reagent3)
Managing of waste4)
Person in charge of
equipment fail5)
-Allocate sharer each item, and put a check mark.
1), 5) The person who bear the cost.
2) The person who obtain authorization about using chemical closet from Unit director and contact person.
3) The person in charge of registration for Chem-RS and managing of reagent.
4) The person who properly dispose of waste liquid and waste after experiment.