Sample Request Distributors Form - Comtrend

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Sample Request Form - Distributors

The Sample Request portal will allow distributor representatives to request sample products. With approval, samples will either ship from Comtrend, or from the distributor with full credit.

Distributor Sample Request Form
1) Distributor Rep Information
Distributor Rep Name*

First NameLast Name
Distributor Rep Email*
example@example.com
Distributor Rep Phone Number
Please enter a valid phone number.
2) Distributor Name
Distributor Name

3) Company Receiving Sample(s)
Company receiving sample(s)
4) Shipping Information
Recipient's Name

First NameLast Name
Recipient's Email
example@example.com
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient's Phone Number
Please enter a valid phone number.

5) Sample Request - (3 Maximum, otherwise, request exception)
Request Sample(s) Model I*
Notes
Request Sample(s) Model II
Notes
Request Sample(s) Model III
Notes
Additional Notes (Optional)

6) Reason for Sample Request (Background)
Reason for Sample Request (background)
7) Competitive & Additional Information
Please add any competitive information (model, price, source), or anything additional you want us to take into consideration.

8) Sample Source (Required)
Distributor stock means you will send and Comtrend will credit the value of product. Comtrend stock means we will send.*

Comtrend (5-10 days via ground)Distributor Inventory (Depends on distributor)
Did you confirm that the customer will test and evaluate within two weeks of receipt?*

YesNo
Please verify that you are human*
Should be Empty:

Are you a Service Provider?