Page 1/6 REGISTRATION FORM PROFICIENCY TESTING PROGRAM MAY 2015 1. 2. 3. 4. Laboratory name: ........................................................................................................................... Company name: ............................................................................................................................. Contact person: ................................................................. Title: .................................................... Address: .......................................................................................................................................... ......................................................................................................................................................... 5. E-mail: ............................................................................................................................................ 6. Telephone number:............................................................ Fax :.................................................... 7. Address for sample delivery (if different to section 4): ................................................................. ......................................................................................................................................................... 8. Telephone number:............................................................ Fax :.................................................... 9. Payment method: By cash; Bank transfer; Request for invoice first 10. Information in invoice: Tax code .......................................................................................................................................... Company name (if different to section 2): ...................................................................................... ......................................................................................................................................................... Address (if different to section 4): .................................................................................................. ......................................................................................................................................................... 11. We apply to participate in the PT programs in 2015 organized by QUATEST 3 (according to official dispatch no.069/KT3-KT), as follows: QPT 06/15 – Milk 15E15 QPT 22/15 – Water 15B15 QPT 07/15 – Feed 15A15 QPT 23/15 – Vegetable 15A15 Notes: - In QPT 06/15 and QPT 07/15, participants are requested to report in CFU/g unit. - Participants need to provide exact information in section 1 - 11 (that will be used during a PT program, when delivering PT samples, inform PT results, make payment …). - QUATEST 3 will only announce the results + codes of lab via email provided in section 5 by the participants. - This is an official registration form, please sign and stamp and tick off the characteristics in the registration form before sending it to QUATEST 3. - Fee include VAT (5 %) but do not include of delivery fee to overseas. Date:…./…./201… REPRESENTATIVE OF COMPANY (Full name/Title) LABORATORY (Full name/Title) ………………………… ……………………………… Please send Registration form via fax, email or by post to the following address: no later than April 15th, 2015 Mai Nha Uyen - Proficiency Testing Provider Unit Quality Assurance and Testing Center 3 No. 7, Road 1, Bien Hoa Industrial Zone 1, Dong Nai province, Vietnam Tel: (84-61) 383 6212 - Ext: 123 - Fax: (84-61) 882 6917 / 383 6298 E-mail: ptprovider@quatest3.com.vn Page 2/6 REGISTRATION FORM PROFICIENCY TESTING PROGRAM MAY 2015 Name of PT program Name of sample Microbiology in milk powder Milk 15E15 Enumeration of Enterobacteriaceae (CFU/g) 01 sample/lab Approx. size: 10 g 2.000.000 đ/lab x “number of lab” Feed 15A15 Enumeration of Escherichia coli (CFU/g) 01 sample/lab Approx. size: 10 g 2.000.000 đ/lab x “number of lab” Water 15B15 Lead (Pb) content (µg/L) Cadmium (Cd) content (µg/L) Arsenic (As) content (µg/L) Mercury (Hg) content (µg/L) 01 sample/lab Approx. size: 250 mL 3.000.000 đ/lab x “number of lab” Nitrate content (mg/kg) 01 sample/lab Approx. size: 100 g 2.500.000 đ/lab x “number of lab” QPT 06/15 Microbiology in feed QPT 07/15 Water QPT 22/15 Vegetable QPT 23/15 Vegetable 15A15 Characteristics Number of sample Number of lab Fee (VNĐ)