PURITAN l Sample Request

Now you can request product samples online, right here. Select from the options listed below. (Limit three per customer, please.) For a product not listed, select "other" and type in the product number. Have questions? Call 1-800-321-2313 to speak with a Puritan representative.

SELECT ONE OR MORE SAMPLES BELOW:

	CLINICAL SAMPLE PACKET	CRITICAL ENVIRONMENT SAMPLE PACKET
	FORENSIC SAMPLE PACKET	COLLECTION SAMPLE PACKET
	ESD SAMPLE PACKET	MEDICAL SAMPLE PACKET
	FLOCKED SAMPLE PACKET	OTHER (please specify)
	DNA-Free SAMPLE PACKET

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CUSTOMER INFORMATION:

First Name

Last Name

Title

Company

Street Address

Suite / Floor / etc.*

City	State / Province

Zip / Postal Code

Country

Telephone Number (xxx-xxx-xxxx)

E-mail Address (for confirmation of product sample request)

* if applicable

SELECT ONE OR MORE SAMPLES BELOW:

CUSTOMER INFORMATION: