Contract to purchase chemicals/gasses This form can be used to order several chemicals or gasses of one and the same firm. Orders can only be processed when the form is filled out completely by authorized applicants OFI-number Type of costs Date: Faculty/Institute/Agency: Applicant: Phone: Final destination Building: Research group: Order number: Signature: There are new hazard statements. If H-statements are unknown you may use the Risk sentences (R-sentences) A Firm: Article number: Amount: Name article/material: Cas-number: H-statements: Very Toxic H300 H310 H330 (was very toxic: R26 R27 R28) Color: Red Roomnr: B Firm: Long-term health danger H340 H350 H360 (was carcinogenic/mutagenic/ reprotoxic: R45 R46 R49 R60 R61 R64) Color: Yellow Cupboardnr: Shelfnr: Article number: All H-statements (numbers) must be completed. If one or more H-statements (or R-sentences) appear in the fields on the left, tick also the box in the relevant field. Own code: Amount: Name article/material: Cas-number: H-statements: Very Toxic H300 H310 H330 (was very toxic: R26 R27 R28) Color: Red Roomnr: C Firm: Long-term health danger H340 H350 H360 (was carcinogenic/mutagenic/ reprotoxic: R45 R46 R49 R60 R61 R64) Color: Yellow Cupboardnr: All H-statements (numbers) must be completed. If one or more H-statements (or R-sentences) appear in the fields on the left, tick also the box in the relevant field. Shelfnr: Bestelnummer: Own code: Hoeveelheid: Name article/material: Cas-number: H-statements: Very Toxic H300 H310 H330 (was very toxic: R26 R27 R28) Color: Red Roomnr: Long-term health danger H340 H350 H360 (was carcinogenic/mutagenic/ reprotoxic: R45 R46 R49 R60 R61 R64) Color: Yellow Cupboardnr: Shelfnr: All H-statements (numbers) must be completed. If one or more H-statements (or R-sentences) appear in the fields on the left, tick also the box in the relevant field. Own code: Applicant certifies that there is in no way a conflict of interests with entering an obligation with the proposed supplier.