AI Technology, Inc. Free Sample Request FormRequested by:Date: MM slash DD slash YYYY Customer: New ExistingCompany:Contact Name:Contact Tel:Contact Email: Carrier:Acct. No.:Ship to Address:State:Country:Bill to Address: Same as Shipping AddressBill to Address (if different):State:Country:Tel:Email:AIT P/N:Paste:Quantity:Jar:Syringe Size:Film:Quantity:Size:Thickness:Coating:Quantity:Size:Special Notes:Approved by:Date: MM slash DD slash YYYY For Internal Use:Test Results:Turned into Sale: Yes NoDate: MM slash DD slash YYYY
