PRODUCT SAMPLE REQUEST FORM

Date

Primary CSR:

Sales Rep Name:(Required)

Requested By:

Sales Rep Acct#:

Distributor / Sales Representative Information

Customer Account # (if know):

Company Name:(Required)

Attention:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone

Is this for End-User?(Required)

End-User Name:(Required)

Reason for the Sample(Required)

Please list End-User Name (s)(Required)

Please Describe Reason?(Required)

Shipment will be sent via UPS Ground Service

IPG Resource #

Order Qty

Order UOM

Product Description / Size

Approvals: UPS RED and UPS BLUE services need approval from Customer Service Management.
Case Qty’s must be approved by Customer Service Management.
Same Day Must Ships must be approved by Customer Service Management.

Comments:

IPG or ECP Samples?(Required)