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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 / 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):
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