Sample Request Form
Download Word Document of
Sample Request Form

Date: ___________________________________

Ship To   Bill To  
Name: ______________________________ Name: ______________________________
Company: ______________________________ Company: ______________________________
Address: ______________________________ Address: ______________________________
  ______________________________   ______________________________
Phone: ______________________________ Phone: ______________________________
Cancel Date (samples must be received by): ______________________________________________
Special Instructions: ________________________________________________
Item Number
Unit Price
Sample Charges:  
01 All samples sent to your customers will be billed to the customer for sample cost and freight.
02 Please include detailed item descriptions with item numbers and complete shipping instructions. If the customer has an account with a ground shipper, please include pertinent UPS/FedEx numbers.
03 Sample cost will be credited to the customer on their first order. Freight costs are the customer’s responsibility and there will be no freight crediting.
04 Please allow 48 hours advanced notice for sample shipping. We will attempt to ship all samples ASAP.
05 New Customers – Credit Application must be attached.