!!ก S !#$%&ก' !#('% / ก (Supply of Microbial Cultures) (Month) (Date) .. (Year) !ก# (Name) &#' (Name in receipt) ________ ,-#./01 (Position) /041# (Institute) 7 #8/7!:#/ก!; (Government) ก> (Private) '/#!4#84 (University, Institute) B14 (School) E#4& . (In house, TISTR) H (Others) J K ________________ >/041# (Name of Institute) 40/041# (Address) 8 (No.) /'0 (Moo) _ O4 (Soi) P (Road) ,-# 8/.1 (District) -#E/, (Amphoe) ___ ;1/ (Province) ________ /:QRST4U (Postal code) BU (Telephone) _________ __________________,0__________ BU'P__________________ B:# (Fax) _________E-mail ,PKRJ:1ZU (Purpose) 1#!;4 (Research) BZ1ก# (Topic) J K: RJก ก#4 ก#: (Education) : /,;: (Testing) method_______________ H J K (Other, please specify): 12 No. ( TISTR No. 82 Name of Microorganism ) !ก# (Client^s Signature) Ampoule ( Z-# !ก# ( Staff) กB12 /D18/EF กGกHIDE2GEJ K: M1 (Date of Lyophilization) ) /D18/EF NJO DO822 M1 Pกก D2ก S 2ก ก Staff only* % / ก BODB กRDกS NTIHD82ODEUBกVPก ก : 2 ก 20 ! 2553 FM-BSD-WI-06-01
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