SAMPLE REQUEST FORM

Instructions: Complete this form to request product samples for evaluation. Submit via email to info@rikaufman.com. Standard samples are provided at no charge for qualified customers. Custom samples may incur tooling or setup fees.

CONTACT INFORMATION

First Name *

Last Name *

Company Name *

Title/Position

Department

Email Address *

Phone Number *

SHIPPING INFORMATION

Shipping Address *

City, State *

ZIP Code *

Preferred Shipping Method

☐ UPS Ground ☐ FedEx ☐ Customer Account #: _______________

SAMPLE REQUIREMENTS

Sample Type *

☐ Standard Catalog Item ☐ Custom to Specification ☐ Match Existing Sample

Sample Details (Please provide up to 3 samples)

Qty	Part Number	Description/Specifications	Application

Evaluation Purpose *

☐ Fit/Form Testing ☐ Performance Testing ☐ Quality Evaluation ☐ Cost Analysis ☐ Other: _______________

Estimated Annual Volume

Target Price Point

Project Timeline

☐ Immediate Need ☐ 30-60 Days ☐ 3-6 Months ☐ Future Project

ADDITIONAL INFORMATION

Special Requirements or Testing Standards

Current Supplier (if applicable)

Additional Comments

Sample Policy:

Standard catalog samples: No charge for up to 3 pieces
Custom samples: May require tooling fee or minimum order
Rush sample requests: Additional fees may apply
International shipping: Customer pays all shipping and customs fees
Samples remain property of Roy I Kaufman, Inc. unless otherwise agreed