MLT Request Samples Form


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	Friday, September 22, 2017

PRODUCT SAMPLE REQUEST

If you would like assistance with your adhesive, coating or other application, please complete the form below.

Please provide as much information regarding your requirements in order for our Technical Department to determine the product selected will be the right sample for your evaluation.

If you have previously requested a sample from MLT and have another application, please contact our Customer Service Department at 1-888-831-4013 for further assistance.

What is your industry
Description of application/Purpose of Sample
End item to be manufactured with MLT product
Current Product Name
Current Chemistry
Substrate to be bonded or coated?
How will the material be applied?
What is the curing equipment that will be used?
Are there shadowed areas Yes No Uncertain
Material properties required (flexibility/hardness, color, clarity, viscosity or fluorescent needs)
How did you hear about MLT?
Sample shipping preference:
If other, enter shipper name:
Enter your shipper account number:

PLEASE FILL OUT THE QUESTIONS BELOW
CONTACT INFORMATION (*Required)
*Preferred Method Of Contact: Email US Mail Phone Fax**
Name*
Title
Company*
Phone*
Fax
E-mail*
Address*
Address 2
City*
State/Province*
Zip/Postal Code*
Country*
Message

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