Sample Request

Sample Policy: Pretium Packaging will send up to 6 samples via UPS Ground free of charge; Expedited freight is the responsibility of the customer. All sample orders are subject to inventory availability

Mold or Item Number: *
Item Description: *
Number of Samples Requested (Pretium will send only 6 at Bottle Size): *
Neck Finish (i.e. 33/400, etc.): *
Gram Weight: *
Your Pretium Sales Person's Name (if applicable):
Name: *
Company: *
Address (No P.O. Boxes please): *
Address 2:
City: *
State/Province: *
Country:
Zip: *
Day Phone:
Fax No:
Email Address: *
Shipping Method (Provided at Pretium's Expense — up to 6 samples):	UPS Ground
Expedited Freight Requests require customer's Account #
Message:
To be Completed by Pretium Sample Administrator:
Sample Ship Date:
Tracking Information:
Sample Administrator Comments: