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Request A Sample

SAMPLE REQUESTED FOR:

*Name:

*Facility/Company:

*Address 1:

Address 2:

*City:

*State:

*Zip:

*Email Address:

*Phone Number:

ARE YOU AN EXISTING DUKAL CUSTOMER / DISTRIBUTOR?

 yes no

Item #

Item Description

Item #

Item Description

Item #

Item Description

Item #

Item Description

PURPOSE OF SAMPLES:

DETAILS OF SAMPLE REQUEST:

NOTES:

SAMPLES WILL BE SENT IN SMALLEST PACKAGING AVAILABLE UNLESS OTHERWISE REQUESTED

**Please Note: Customer/Requestor is responsible for all freight charges on deliveries outside contiguous US.
A valid shipper name and account number must be provided at time of sample submission.