SAMPLE REQUEST
*
indicates a required field.
Name:
*
Company:
*
Address:
*
City/State/Zip:
*
Phone No:
*
Fax No:
E-mail:
*
Product:
Sample Size:
Sample 1:
Sample 2:
Sample 3:
Standard Sample Sizes - Liquids = 200 ml Powders = 400 g
If sample other than standard sample required – please specify
The following information must be provided (in full) in order for
Nease Corporation to process this sample request.
Application:
*
Market:
*
Household
Industrial & Institution
Personal Care
Textile
Oilfield
Paints & Coatings
Other (specify):
Potential Usage:
*
Less than truckload
Truckload
Bulk
Who do we contact for follow up and when?
Name:
*
Title:
*
Phone:
*
When:
*
Are you a distributor
:
*
YES
NO
Other Comments:
