Sample Request

Please fill out this form completely and click submit when finished.
Requested By*
Date*
MM slash DD slash YYYY
Select Company Type*
Company Name*
Email*
Phone*
Sample to be:*
- Pick-Up at OPCC
- Send with Order
- Pulled from Distributor Stock
- Ship Next Day Air
Date for Pick-up*
MM slash DD slash YYYY
Distributors are NOT authorized to deduct. If pulling product samples from stock, Distributor must send bill-back invoice to: rose@phillycheesesteak.com.
Order PO#
Requested Delivery Date
MM slash DD slash YYYY
FedEx Account #
To/Attn
Company
Address Line 1
Address Line 2
City
State
Zip
Phone

Special Request & Instructions
Sample Qualification
The Samples are for:*
- Existing Customer
- Prospective Customer
Customer/Prospect Name*
Estimated Weekly Volume*
Original Philly Product Currently Buying
Current Distributor
Briefly Describe Reason for Sample Request
Outcome of sample cutting must be reported within 2 weeks.

Please follow-up using Sample Results Form.
Post Custom Field