Sample Order Form
Complete your details below and have a sample sent to any location in the US
Rep
Dealer
Employee
First name
Last Name
Your Company Name
Your Email Address
Your Phone Number
Add products
Quantity
Item Number
Product Description
Sample Price
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This sample will be shipped to
Company Name
Ship to First Name
Ship to Last Name
Address
Address 2
City
State
Zip
Email address of the receiver
Phone number of the receiver
Requested arrival date
Is there important information about the requested arrival date you’d like us to know about?
Shipping location details
Is this a Residential or Business Address?
Residential
Business
Is Special Handling required?
Yes
No
Is Inside Delivery required?
Yes
No
Is a Lift Gate required?
Yes
No
Are there additional important shipping notes you’d like us to know about?
Order details
Quantity
Item Number
Product Description
Sample Price
Extended Cost
38
354694
Synchronous-flex and swivel motion provide comfort
$12,500.00
$475,000.00
20
469896
Integrated handle design for hanging bag or jacket
$18,500.00
$370,000.00
Total
$105,625.00
Is there a customer PO number?
Yes
No
Enter PO
Upload your purchase order
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