Information/Samples Request Form

	Information / Samples REQUEST FORM
7424 Victor-Mendon Rd Victor, NY 14564	585-924-7316 Tel 585-924-3868 Fax

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Free Information/Samples

Is there a specific product you want to try but have hesitated?

Why not ask for a Free Sample?

Simply fill in the form below to place your request for a free sample or for literature.

1.	Manufacturer:
2.	Product:
3.	Send catalog Send sample Send info
4.	Have a sales rep contact me Information only
5.	Present Need Future Need
6.	Schedule Required: 0-6 months 6-12months 12 months+

7.	Name:
	Company:
	Address:
	City:
	State:	Zip Code:
	E-mail:
	Tel:
	Fax:

All fields must be completed to receive samples.