LAB SAMPLE REQUEST FORM

This form can be used to request 8" x 10" (20 x 25cm) lab samples of a single décor, a standard combination or a custom combination.

Use these questions to help you specify the correct product:

Does the project require Class A Fire Rating? (If yes, choose Lumiform resin.)
What gauge should be specified for the size of the piece? (For help determining gauge requirements, use the Deflection Matrix.)
How will the sheet be installed? (Vertical, Horizontal, Framed, Standoffs, etc. View Lumicor hardware info.)
Does the project require Add-Ons such as Illume or Chemshield? (View Lumicor Add-On info.)
Are there any size limitations to the decor that has been chosen? (Go to the desired décor product page to determine gauge and panel size limitations.)

Project Name *

Application *

Sales Rep Company *

Sales Rep Name *

Contact E-mail *

Specifier Name *

Lab Sample Fee Payment Options
Single Décor and Standard Combo Samples = $25.00
Custom Samples = $75.00 *

Purchase Order Number *

Customer Name *

Billing Address *

Unit

City *

State *

Zip Code *

Email Address *

Phone Number *

SHIPPING INFORMATION

Delivery Method *

Ship to Address

Will Call (Renton, WA)

Delivery Method2 *

Use Billing Address (above)

Ship to a different address

Will Call (Renton, WA)

Shipping to Company *

Name *

Street *

Unit

City *

State *

Zip Code *

Name of person picking up order *

E-mail *

Phone Number *

What kind of Lab Sample do you need? *

Single Décor

Standard Combo

Custom Combo

How many DIFFERENT décors do you need to quote? *

How many DIFFERENT standard combos do you need to quote? *

How many custom combos do you need to quote?
*