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 4" x 6" swatch book

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

	Wallscapes 3.5" x 8" swatch book

	BIOflex- (Biodegradable PVC) literature packet with swatch

	Bar Runner (hand sample)

	Logo Mat (hand sample)

	Carpet (UV & solvent)
	Printed hand sample		Unprinted hand sample

	Progress carpet (dye-sub UV & solvent)

Please specify other samples needed and their quantities, such as printed or unprinted hand samples of a specific product or sample rolls (for test-printing) of a specific product. Sample rolls are typically 56" - 60" x 20' for UV, solvent & screenprinting. For sample rolls, please specify matte or gloss 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