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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
