Sample Request Form
Epoxy Insulating Coating Powders
Durable Dielectric Molding Compounds
Optoelectronic Molding Compounds
CUSTOMER
REQUESTOR INFORMATION
:
Market Partner Contact Information
Company Name
Enter Company Name
Phone No
Enter Phone No
Contact Name
Enter Contact Name
Job Title
Email
Enter Email
Enter Valid Email
SAMPLE SHIP TO INFORMATION
Same as Requestor Information
Company Name
Enter Company Name
Phone No
Enter Phone Number
Contact Name
Enter Contact Name
Job Title
Customers Email
(Shipping Documents will be sent here)
Enter Customers Email
Enter Valid Email
Address Line 1
(match Address Line1 entered on an envelope)
Enter Address Line1
Address Line 2
(match Address Line2 entered on an envelope)
Enter Address Line2
Address Line 3
(match Address Line3...)
Enter Address Line3
Address Line 4 (match Address Line4...if applicable)
Address Line 5 (match Address Line5...if applicable)
Market Partner Emails(s)
(must use a comma to separate each email address)
SALES
APA Number
Purpose of Sample
If no APA list purpose of sample
Is technical support required?
Yes
No
Material Type (Select One):
Select One
Opto
Coating Powder
Molding Compound
Liquid
Select Material Type
Product Type
Commercialized
Notebook
Select Product Type
Quantity Requested:
Kg
Enter Quantity Requested
Only 2 Decimals Required
Pellet size:
Instructions
mm
Only 2 Decimals Required
Height
or
Weight
mm
Only 2 Decimals Required
g
Only 2 Decimals Required
Requested Delivery Date:
(Date of arrival at Ship-To address)
Enter Requested Delivery Date
Freight Charges Billed To?
Customer
SolEpoxy
Freight Fowarder Name:
Enter Freight Fowarder Name
Freight Fowarder's Account No.:
Enter Freight Forwarder's Account No.
Comments
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