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SAMPLE or CONSIGNMENT REQUEST Form:
F-CS-4.3-01-02
Rev:
AG

Date: / / (mm/dd/yyyy)

 
Requested by:
Distributor/ Representative / Company:
Contact:
Distributor/ Representative / Company Email:
Distributor/ Representative / Company Phone#:
End Customer Name:


Qty.
Catalog No.
Description

 

Ship To: Phone:
Contact: Fax:
Attention:    
Address:
City: State: Zip


THE FOLLOWING MUST BE COMPLETED:
New Project? Yes No Is there a competitive product currently used?
Yes No
If Yes , Manufacturer:
  Are there any special customer requirements
(if so please list)?
Delivery Requirements /
Release Schedule:
Altech Representative:

 

For more information contact Altech at:
908-806-9400 • 908-806-9490 (FAX) • info@altechcorp.com • 35 Royal Road, Flemington, NJ 08822