Samples & Information Request Form

Instructions:

  • Tip:  Please ensure you have all information available to complete your online form prior to filling it out - contact information, product name, code, description, and color.  You may lose data that has been input if you leave the Request Form prior to submitting.
  • Shortly after submitting an order, an automatic confirmation email from kostklip® will be sent to the email address entered, which will include the request details and the reference number.
  • One (1) sample part of each requested will be sent, and the request will be processed within five (5) business days.  Samples and information are sent by standard ground mail unless otherwise specified below.
  • For any questions, please contact Customer Service at 1.800.661.5547 or email



* indicates a required field
Company InformationContact Information
Business Name *
First Name *
Billing Address *
Last Name *
P.O. Box / Suite / Unit
Title
City *
Department
Prov/State *
Phone *
Country *
Fax
Postal/Zip Code *
Email *
Shipping AddressFreight Information
Select if Ship To address is same as Billing Address
Shipping Payment Method *
Pre-Paid
Expedited (Collect) -- please complete all carrier information
Shipping Address
Select One:
Ground Air
Freight Carrier
City
Bill To or 3rd Party Account #
Prov/State
Special Shipping Instructions
Country
Postal/Zip Code
Literature
Yes, please send me a free catalog.
Yes, please send me information about the ClearVision® program.
I am interested in learning more about the ClearVision® program – please have a Sales Representative contact me.
Yes, please add me to your eNews mailing list. (See our Secure Privacy Policy)
Samples Requested
Product NameCodeColor †Description
† Color may be substituted if not available as indicated.
* I have read and agree to the Terms of Use:
  1. If the requested product sample color cannot be satisfied, kostklip® reserves the right to send the product sample in the next available color.
  2. If Expedited Shipping is selected for product samples, freight will be paid collect on the customer’s carrier.
  3. Requests for literature will be shipped via regular mail, unless product samples have been requested in which case both will be shipped according to the shipping service selected.
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