DATE:

  1. INTRODUCTION

This questionnaire will provide Matrix Fine Chemicalsthe information needed to qualify the raw materials for production use. Your participation will ensure the widest possible use of your products in Matrix Fine Chemicals applications. Please fill in all questions without leaving any blank. If any questions are not applicable, indicate “N/A”. Additional pages may be attached if necessary.

CHECK LIST

Please use this checklist to ensure the requested information is provided.

1 / Product Specification / Yes No
2 / MSDS attached or explanation why an MSDS is not required / Yes No
3 / All analytical methods or explanation why you are not able to provide it / Yes No
4 / Technical documentation or explanation why you are not able to provide it / Yes No
  1. GENERAL INFORMATION ON MANUFACTURER / VENDOR

Supplier Name: / Supplier Product Name:
Supplier Product Code: / Production site Address:
  1. IDENTITY

COMPOSITION

List all major components/isomers and include approximate percentage and the analytical method:

Chemical Name / CAS number / Amount % / Analytical Method

List all known impurities and include approximate amount (at least the components bigger than 0.5 %).

Chemical Name / CAS number if known / Amount
  1. QUALITY INFORMATION

PHYSICAL DESCRIPTION

Physical State:Clear liquidCloud liquidGas Solid

Powder/GranularViscous liquidOther

For Powder/Granular:

Please attach the particle size distribution (PSD): AttachedNot attached -- Reason:

Powder Flowability:

Dry content and method:

Explosion parameters:

Contain free flow and anticaking agents:NoYes-- Name of additive:

Solubility: Water Ethanol Other:

CHEMICAL/PHYSICAL ANALYSIS

Result or specification range / Analytical Method
Colour
Specific gravity D20/20
Refractive index nD20
Acid or base value
pH value
Peroxide value
Water content
Viscosity
Optical rotation D20
Flashpoint (°C, closed cup)
Melting point
Boiling point
Others
  1. RESTRICTED MATERIALS:

Does it contain any solvents or carriers: YesNo-- Name and quantity in %:

Does it contain any antioxidants:YesNo-- Name and quantity in %:

HEAVY METALS

If the product contains heavy metals, please indicate actual amounts in the text fields.

Lead ppm / Cadmium ppm
Mercury ppm / Arsenic ppm
Copper ppm / Antimony ppm
Selenium ppm / Tin ppm

GMO

Can you certify that the raw material is GMO-free?Yes No

If no, please provide the identifier for the GM varieties:

Regulations

Is this raw material or any of its major components or impurities considered as an illicit drug or drug precursor by the legislations of Switzerland, USA, EU? Yes No

If yes, please state for which country:______

  1. PACKAGING & STORAGE

Available standard packaging:

Recommended Storage conditions (include temperature):

Shelf Life/Stability:

  1. DECLARATION

We hereby declare that the above information is to the best of our knowledge, correct and complete. Unless written notification is given by us to the contrary, the above information will be applicable to all future shipments of the abovestated product.

For and on behalf of

Name and Title

Date

WARRANTY

The supplier warrants that the material supplied is of sound quality and is supplied to Matrix Fine Chemicals conforming to all aspects of this specification. The supplier agrees that Matrix Fine Chemicals shall reject any consignment which fails to meet the requirements specifiedin this document unless prior written agreement has been reached between thesupplier and Matrix Fine Chemicals. If such agreement is reached the supplier acceptsresponsibility for any extra legitimate costs incurred by Matrix Fine Chemicals in handling andusing the material.