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SAMPLE REQUEST

Please use this form to request samples of our products. There are four (4) items which MUST be completed: 1.) INTENDED APPLICATION (USE) 2.) QUANTITY (1 or 2) NOTE: 1 is a sample 2 is an order. Any quantity larger than 2 will require a $25.00 charge. 3.) UPS/FED EX ACCOUNT NUMBER (REQUIRED) What if I don't have an account number? 4.) Complete shipping information including accurate telephone number, email and physical address.

*Please fill out completely. Required fields are marked with an asterisk ( )**
*First Name:
*Last Name:
Company:
Title:
*Address 1:
Address 2:
*City:
*State/Province:
*Zip Code:
*Country:
*Telephone Number:	Ext
Fax Number:
*Email Address:

*Ship Via :	Fed Ex UPS Will Call
*Account Number:	*What if I don't have an account number?*
*Shipping Method:	Next Day / Overnight 2nd Day 3 Day / Express Ground (5-7 Business Days)
Reference Number:
Notes/Comments:

*Item Description:
*Part Number:
*Intended Application (Use) :

Item Description:
Part Number:
Intended Application (Use) :

Item Description:
Part Number:
Intended Application (Use) :