Rectangular Brush Sample and Pricing Request Form

		Name *
		Company
		Address *
		City *
		State *
		Postal Code *
		Country *
		E-mail *
		Phone *
		Fax
Sample	Quantity
Pricing	Annual Qty
	Release Qty
A - Fill Material

B - Trim Density	Light Medium Heavy Extra Heavy
C - Trim Height
D - Base Thickness
E - Overall Length
F - Base Width
Fill Color
Application
Comment/Question
	* Denotes required field