ADDA USA Sample Request Form

ADDA USA Sample Request Form 1150 W. Central Ave. # C, Brea, CA 92821 Phone: (714) 674-7921, Fax: (714) 257-7486

Requested By: (Company) Date Requested:

Contact Person: Email:

Tel: Fax:

Address: State: Zip Code:

ADDA Model No. / Qty. / @Price / Potential / Shipping Date Required / / / / / / / / / / / / / / / / / / / / / / / / / / / /

Data Sheet Requested:  YES  NO Safety Sheets Requested: YES NO

Shipping Information: Shipping Address:

City: State: Zip Code:

Tel: ( ) - Fax: ( ) -

Ship By: UPS RED Blue Orange Regular Account #:

Fed Ex: Priority Overnight Standard Overnight Fed Ex 2 dayAccount #:

Other: (Please Specify)

Customer or End-User Information: Company: Contact: Project Name: Address: City: State: Zip Code:

Tel: Fax:

Please Fax Back to: ADDA USA (714) 257–7486

Approved By ADDA USA (For ADDA USA Only) Name: Date: Scheduled Shipping Date: ADDA USA Ref. No. Comments: