Sample Request Form
SAMPLE REQUESTED FOR:
*
Name:
*
Facility:
*
Address 1:
Address 2:
*
City:
*
State:
*
Zip:
*
Email Address:
*
Phone Number:
SAMPLE REQUESTED BY: (if different than above)
Name:
Facility:
Address 1:
Address 2:
City:
State:
Zip:
Email address:
Phone Number:
ARE YOU AN EXISTING DUKAL CUSTOMER:
Yes
No
Item 1 Number:
*
Item 1 Description:
Item 2 Number:
Item 2 Description:
Item 3 Number:
Item 3 Description:
Item 4 Number:
Item 4 Description:
Item 5 Number:
Item 5 Description:
PURPOSE OF SAMPLES:
Customer/Facility Evaluation
Government/City Bid Evaluation
Personal
SAMPLES WILL BE SENT IN SMALLEST PACKAGING AVAILABLE UNLESS OTHERWISE REQUESTED