ONLINE REQUESTS MUST BE SUBMITTED TO CUSTOMER SERVICE USING THE SUBMIT BUTTON AT THE BOTTOM OF THIS FORM.

IF YOU PREFER TO FILL IN THE FORM BY HAND AND FAX OR HAND SUBMIT, CLICK HERE, THEN SELECT 'SAVE' IN THE DIALOG BOX TO SAVE TO YOUR COMPUTER.  AFTER SAVING THE WORD DOCUMENT TO YOUR HARD DRIVE, YOU MAY ALSO TYPE DIRECTLY INTO THE FIELDS, SAVE AS, THEN EMAIL THE WORD DOCUMENT TO CUSTOMER SERVICE AS AN ATTACHMENT.

Salesperson:     Sales Number:          

Account:      Account Number:          

Samples or Tasting?        choose one sample tasting     Pick Up Date:      

Reason for Request:            

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

Item #:    Quantity:    Product Description:

TO SUBMIT YOUR REQUEST, CLICK ON YOUR CUSTOMER SERVICE REPRESENTATIVE'S NAME: