1. Sample Request
Buffalo Customer Service Fax: 716-656-8239
REQUEST DATE: 6/22/2016 TM #:
TM NAME: DSM NAME:
PART I – Billing Info
BILL TO:
VENDOR
(requires Broker approval)
SALES # 80747918
(requires DSM approval)
Vendor Name:
Vendor #:
Broker Name:
Approval/PO #: (if issued by Broker)
OBJECTIVE / REASON:
PART II – Product Info
Product # Description Qty. Pack
case each
case each
case each
case each
PART III – Customer Info
DATE OF SAMPLE:
PICK UP:
Will Call
SHIP TO:
Customer
Rochester
Office # 788448
Customer #:
Account Name:
Contact Name:
Phone #: (if requested by Broker)
SAMPLE REQUEST FORM