Sample Request

1. Name:

2. Title:

3. Company:

4. Address:

5. Address Line 2:

6. City:

7. State/Prov.:

8. Zip/P.C.:

9. Country:

10. Phone:
    Ext.
    
11. Fax:

12. E-mail:

13. Color Name/Description (and part # if known):

14. Type of Container (Check all that apply):
15. 12 oz. Aerosol
16. Approximate Usage Qty. (100 min.)

17. 6 oz. Aerosol
18. Approximate Usage Qty. (100 min.)

19. Brush-in-Lid Bottle
20. Approximate Usage Qty. (100 min.)

21. Paint Marking Pen
22. Approximate Usage Qty. (100 min.)

23. Other (Describe in “Special Notes” below)
24. Approximately how long will above Order Quantity last?
    Months

Additional Information

1. Type of surface to be touched up
   Bare metal
   Painted
   Other

2. Primary Light source? Check all that apply.
   (If more than one, list in “Special Notes”.)
   Daylight
   Fluorescent
   Incandescent
3. Resin system type? (see notes below)
   No preference
   Enamel
   Lacquer
4. Aerosol spray pattern?
   Fan
   Round
   N/A
   Other

5. Aerosol carton size?
   12-pak
   6-pak
   N/A
   Other

6. Aerosol cap type?
   Small 1″ stacker cap
   Large double-shelled (DS) cap
   N/A

Labeling Requirements

1. No preference (Custom-Pak stock label)
2. * Semi-private label using your company logo
3. * Multi-color private label
4. * – One-time label development charges will apply
5. Special Notes?
   (Provide details about your Sample Request, i.e. performance requirements, VOC issues, etc.)
   
   
6. 
   How did you hear about us?

Before hitting the submit button, please print out the completed form and send it with your color standard samples.