Pure Fiji Sample Request Form

TODAY'S DATE

SALES REPRESENTATIVE


BUSINESS NAME

PHONE

CONTACT NAME

EMAIL

TITLE

WEBSITE


BILLING ADDRESS STREET

CITY

STATE/PROVINCE/COUNTRY

ZIP

SHIPPING ADDRESS STREET

Same as Billing Address

CITY

STATE/PROVINCE/COUNTRY

ZIP


REASON FOR SAMPLE REQUEST

New Customer Enquiry

Existing Account Adding Fragrance Or Line

Customer Service Issue **

Customer Promotional Event **

Press Sample Request **

Other **

IF YOU SELECTED A CHECK
BOX WITH ** PLEASE
PROVIDE FURTHER INFORMATION

(Requests Related to Promotional/Press Events Are Automatically Forwarded to Marketing)


PLEASE SPECIFY TYPE OF
SAMPLE REQUESTED

Body Samples     Facial Samples     Gift Samples    


PLEASE SPECIFY YOUR
MAIN PRODUCT FOCUS

Retail Only     Treatment Only     Both Retail & Treatment


PLEASE SPECIFY
FRAGRANCES REQUESTED

Coconut     Coconut Lime Blossom     Coconut Milk & Honey     Dilo     Frangipani    

Guava     Herbal Detox     Island Bliss     Mango     Orange Blossom    

Passionflower     Pineapple     Starfruit     White Gingerlily    


PLEASE SPECIFY CUSTOMER'S
PREFERRED PRODUCT SIZE AND
AMOUNT REQUIREMENTS


OTHER SPECIAL CUSTOMER
REQUIREMENTS