Sample Request

Product Sample Request Form

If you would like free samples, or if you would like more information or production specifications, please complete this form. The samples you have requested will be sent to you shortly. If the product you have requested are not currently available, we will send you an alternative.

Customer Information

If you are the distributor please list yourself as the customer.

Name :
Title :
Phone :
Fax :
E-mail :

Ship to Address

Our Samples are free only if you pay the shipping.

Express :

DHL	UPS	FedEx

Company Name :

Contact Name :

Address :

City :

State/Province :

Zip/Postal Code :

Country :

Telephone :

Line Detail Information

So that we can process your request, please read and complete all fields.

Application :
Resolution :
Product Number :
Quantity :
Request Date :
Line Note :