SAMPLE REQUISITION FORM
Lab
Field
Other (Please Specify )
Company Name:
Contact Name:
Designation:
Mailing Address:
City:
Zip:
Country:
Phone No:
Fax No:
Email Address:
Product Name & Description:
(Please provide all possible relevant
technical information)
Grade:
Form:
Quantity:
Type of test:
Is this product being used
by your company currently:
If Yes: Current source:
Reason for evaluation
of another source:
Current application:
Annual consumption
of this product:
If Not: Potential application:
Potential annual consumption
of trial product:
Market Segment:
Current Manufacturing process
(please provide
all relevant technical details):
Kgs
Production
No
Yes
mt
mt
Tyre
Man Made Fibre
Plastics
Pharmaceutical
Other- Please Specify
