Ultraflexx Request Sample Form

Sample Request Form

*EFFECTIVE JANUARY 2008- REQUESTOR WILL BE RESPONSIBLE FOR ALL FREIGHT CHARGES. SAMPLE MATERIALS ARE FREE OF CHARGE.

Please fill in the form below to complete your request
All areas with a * must be filled in.

Product information/swatches:

Specify quantity of each:

	Full Product line swatch book 4" x 6"

	Full Product line Hard Cover Binder 10" x 12" with spec sheets & swatches

	Product Sell Sheets (Front-lit, Black-lit, Mesh, Blockout, Specialty Textiles)

	BIOflex (Biodegradable PVC) literature packet with swatch

	Hand Sample Printed 8" x 10"

	Hand Sample Unprinted 8" x 10"

Sample Roll 30" x 25'
(please provide product name and finish)

Requestor details:

*Your Company:

*Your First Name:

*Your Last Name:

*Phone#:

ext.

Fax#:

*Email Address:

Web Address:

Shipping Details (we can ship direct to you or your customer):

*Attention
(receiver's name):

*Receiving Company Name:

*Company Address:

*City: *State: *Zip:

*Phone#:

ext.

Fax#:

*Email Address:

Web Address:

*Printer(s) your Customer/receiving company has (specify Name and Model):

-We will process and ship your request within 24 hours. If you are not contacted, your request will ship to the address provided. ** larger quantities will be considered upon special request **

Please select a shipment destination and a carrier:

(note- choose a carrier for which you can provide an account #):

This is my account number

This is my Customer’s account number

Thank you! For help with samples please call the Marketing Department at (973) 627-8608 ext. 119