Sample Request – Test Please read and follow these instructions:PO# will be assigned and added by the admin or samples teamThis form will be rejected if incomplete/missing informationIf there is a cost for a non-returnable sample, this will need to be reviewed and approved prior to orderingBuy/Sell other than for personal use (family or friends), must have prior approvalAccommodation order requests must always receive prior approvalAcuity sample orders must also use this form. Samples are at no charge, and all logistics are handled through Acuity (ESD, tracking numbers, etc.)Job Name(Required)Project Number(Required)Distributor(Required)Manufacturer(Required)Sales Person(Required)PO Number(Required)Sample Type(Required)Select OptionSampleBuy/SellAccommodationReason for accommodation request?QuantityDescriptionBuySellQuantityDescriptionBuySellQuantityDescriptionBuySellQuantityDescriptionBuySellQuantityDescriptionBuySellQuantityDescriptionBuySellQuantityDescriptionBuySellFreightBuySellTotalBuySellShip To Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping InstructionsΔ
