200 Three Rivers Pkwy
North Bend, Ohio 45052
P: (513)467-0222
F: 866-518-3913

Ticket System - Rev. C


Use this form to request product samples.
Upon sending this form you will receive an email link to a ticket
where you can check the status of your request.
Expect a response from us in 1 business day.
Please note that Required fields are marked with *.
Thank you for your interet in our products.

Sample quantities:
Membrane Filters - 3 pieces
Syringe Filters - 3 pieces
Capsule Filters - Not Available
Roll Stock - 1 pc. 8" x 10"
Reusable Filters - 1 piece
Disk Filters - 1 piece
Mesh Filters - 3 pieces
Name *

Subject *
  *Quantity *Product Number / Description
First Sample
  Estimated single purchase amount

Second Sample
  Estimated single purchase amount

Third Sample
  Estimated single purchase amount

  *Ship to Company
  *Shipping Address
Please note that there may be a charge for samples. In this event, one of our Customer Advocates will contact you.