MANUFACTURER'S INFORMATION REQUEST FORM

Please Note: This form is to be used only by qualified manufacturers and distributors of foods, nutraceuticals, beverages cosmeceuticals and pharmaceuticals. Sorry, we cannot answer consumer enquiries.

Requests for Samples

Samples may only be obtained by faxing your request on your official company letterhead / stationery to
1-559-594-4689

* = Required Field

*First Name:		*Last Name (surname):
Title or Position:		Job Function:
*Company Name:
*Street Address:
*City:		State or Province:
*Country:		Postal Code:
Email Address:		Company website:
Telephone:		Fax:
In U.S.A. please include area code. If outside U.S.A. please include city and country codes

How would you like to be contacted? (check all that apply):
Email	Fax
Air Mail	Telephone

What is your company type? (check all that apply):
Trading Company	Bakery Product Manufacturer
Importer / Distributor	Snack Foods Manufacturer
Commissioned Agent	Healthy or Dietetic Foods Manufacturer
Consultant	Cosmetics Manufacturer
Government Office	Dietary / Nutritional Supplement Manufacturer
Beverage Manufacturer	Pharmaceuticals Manufacturer
Dairy Products Manufacturer	Other Manufacturer (please list below)
If "Other" checked, please list:

Comments:

*Form Validataion (to prevent auto script spam):

Please enter ONLY the FOUR highlighted numbers shown in the above series of digits: