Research Centre for Toxic Compounds in the Environment, Kamenice 753/5, Pavilion A29, 625

Research Centre for Toxic Compounds in the Environment, Kamenice 753/5, Pavilion A29, 625 00 Brno

/ APPLICATION FORM for open access
Trace analytical laboratory
for external users

ACADEMIC YEAR 20 / 20

APPLICANT’S PERSONAL DATA

Family name:
Date of birth:
Nationality:
Place of Birth:
Current address:
Tel.(mobile):
E-mail: / First name(s):
Permanent address (if different):
......
Date Signature of applicant

SENDING INSTITUTION

Institution type
University or other higher education organisation
Scientific research institution
Company
State administration
NGO
Name and full address of institution:
Supervisor(in case of student or junior scientist)
Name:
Telephone /Fax numbers:
E-mail address:

PROJECT/PROGRAMME

Name:
Work at the RECETOX Infrastructure: YES NO
( If YES, please continue with part A)
Using the infrastructure without stay (just samples/data analysis): YES NO
( If YES, please continue with part B)

PART A

Planned stay at the RECETOX Infrastructurefrom: till:…………

Financial support of your stay:

laboratory work, travel and accommodation covered by own project

laboratory work supported by the RECETOX Research Infrastructure project +

travel, accommodation, etc. covered by own project

laboratory work supported by the RECETOX ResearchInfrastructure project +

travel and accommodation, etc. covered by the host institution

Equipment required:

Type of analysis:

Sample(s) description (origin, size, history, compatibility,…):

Project duration (hours):

Service required:

Full service (sample preparation and analysis)

Full sample preparation and assistance with analyses

Full sample preparation without analysis

Assistance with sample preparation and analysis

Assistance with sample preparation

No assistance

Data interpretation and visualization:

Do you need the final results? YES NO

Do you want just raw data to be calculated yourself? YES NO

Could data be import data to GENASIS database? YES NO

data public available YES NO

If yes, please note, data sets to be imported into the GENASIS database have to contain specific mandatory information listed below (cross marked items in the list). The items below are required for correct import and integration of your data into the GENASIS database):

Site description:

☒Name of the site

☒Geographic coordinates of the site

Sample description:

☒Matrix (including specification)

☒Sampling method

☒Sampling date (e.g. from/to)

Expected outcome:

Thesis (Bachelor, Master, Ph.D)
Progress/Final report
Poster
Conference presentation
Peer reviewed article
Other (please specify)

PART B

Note: All procedures are in the regime of the Trace laboratory infrastructure.

What do you need?

sampling

samples clean-up

analysis

data interpretation

How many samples?

Which compounds do you want to analyze?

In which matrices?

Data interpretation and visualization:

Do you need the final results? YES NO

Do you want just raw data to be calculated yourself? YES NO

Could data be import data to GENASIS database? YES NO

data public available YES NO

Site description:

☒Name of the site

☒Geographic coordinates of the site

Sample description:

☒Matrix (including specification)

☒Sampling method

☒Sampling date (e.g. from/to)

Expected outcome:

Thesis (Bachelor, Master, Ph.D)
Progress/Final report
Poster
Conference presentation
Peer reviewed article
Other (please specify)

Is the excel file with sample description attached? YES NO

Other comments (if is needed)

RECEIVING INSTITUTION

(to be completed by the host institution)

Technical feasibility of the proposed research project at facility YES NO

Date: Signature of core facility head:

Scientific excellence of the proposed research project YES NO

Quarterly decision made by Extended Executive Board
We hereby confirmed that the above mentioned applicant is
accepted at our institution from (month) (year) till (month) (year)
not accepted at our institution
Co-ordinator responsible (guarantor/supervisor)
Name:
Telephone /Fax numbers:
E-mail address:
...... ......
Date Signature of Centre director/infrastructure coordinator Stamp of institution

RECETOX Research Infrastructure – Research Centre for Toxic Compounds in the Environment,
ID number LM2015051, is funded by the Ministry of Education, Youth and Sports of the Czech
Republic under the activity „Projects of major infrastructures for research, development and innovations”.