Sample Request | US Polymers-Accurez

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If you have questions about the application of a specific resin, please reach out to our experienced chemists and we will help ensure that the sample you are requesting best suits your needs.

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Sample Request Form

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Sample Requester Information

Who is requesting this sample

First Name *

Last Name *

Email *

Distributor *

Chem Materials

Dorsett & Jackson

Van Horn, Metz & Co. (VHM)

Other (please specify)

Sample Recipient Information

Who will receive the sample(s)?

Recipient First Name *

Recipient Last Name *

Recipient Company Name *

Recipient Company Address (We need a building address. Samples cannot be sent to a P.O. box) *

Country

City

State

Zip code

Recipient Email *

Sample Information

Please provide info regarding the sample(s) you would like to receive.

Please briefly describe the application for the requested sample(s) *

If the sample you're requesting is intended as a replacement for an existing resin, please provide the commercial identity of the resin you are seeking to replace.

Product Name 1 *

Product Name 2

Product Name 3

Product Name 4

Sample Request Quantity (Samples larger than 1 gallon require payment info, please contact USPA sales ) *

1 Quart (standard)

2 Quart

1 Gallon

If the resin sample you've requested is approved, approximately how much product do you anticipate using per year. *

< 8K lbs

8k-15k lbs

16k-3k0 lbs

31k-50k lbs

5k1-100k lbs

> 100k lbs

Special instructions or other info

How did you hear about USPA *

I'm an existing customer

Google

UL Prospector

Referral from a colleague

NAPIM (National Institute of Printing Ink Manufacturers)

SLPCS (St. Louis Paints and Coatings Society)

Other (please specify)

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