Full Name
First Name
Last Name
Company/Organization Name
Job Title/Role
Industry
Email Address
Phone Number
Website/Social Media Link
Current Annual Spend in this Category
Product Name/SKU Requested
Quantity Needed (e.g., 1 unit, 5ml vial, etc.)
Variation (if applicable): (Color, scent, size, or model number)
Primary Purpose of Request
Internal Testing/Quality Evaluation
Content Creation (Review/Social Media)
Potential Bulk Purchase/Wholesale Partnership
Comparison against current supplier
Who will be performing the testing?
Evaluation Timeline: How many days or weeks do you require for product testing?
Success Criteria: What specific features or results are you looking for during this trial?
Projected Monthly/Annual Volume: (If the evaluation is successful)
Projected Launch/Purchase Date
Decision-Making Process
I am the sole decision-maker.
Evaluation results will be presented to a board/committee.
This is for a client project (Agency/Contractor).
Shipping Address
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Preferred Shipping Method
Shipping Account Number (Optional): (e.g., FedEx/UPS/DHL if the requester is paying for freight)
Is this a rush request?
Note: By submitting this request, the requester agrees to provide feedback within 14 days of receiving the sample. Samples are provided for evaluation purposes only and are not for resale.
Signature
Form Template Insights
Please remove this form template insights section before publishing.
This section is about Lead Scoring. By asking for a company name and a professional email address, you can quickly distinguish between a "freebie seeker" and a genuine business partner.
Specificity prevents waste. By forcing a requester to choose a specific SKU or variation, you ensure they have actually researched your catalog.
This is the most valuable part of the form for your internal data.
Small businesses often struggle with the cost of shipping samples.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation before publishing.
Below are the essential fields for a Product Sample & Evaluation Request Form and the operational reasons for their inclusion.