Online Sample Request Form

This Sample Request form has been provided to assist you in obtaining samples of products you are interested in purchasing.

You may wish to print this form out and then fax it to us at (559) 275-1753, or you may call our toll-free number (800) 760-TILE (8453) and give us the information over the phone.

Sample Requested by

First Name: Last Name:
Address:
City:
State/Province:
Zipcode/Postal Code:
Day Phone: Area Code: Number
Evening Phone: Area Code: Number
Your Email:

Ship to Address:

Ship To Name:
Ship To Address:
Ship To City:
Ship To State/Province:
Ship To Zipcode/PostalCode:
Location Type:

I would like a sample(s) of the following:

Product Type Other Product Name Item Code Product Size Sample Cost

Total Cost:

Please provide the following

Method of Payment:
Name on Credit Card:
First 8 digits of Credit Card Number: (Please make sure you have 8 numbers entered)
Last 8 digits of Credit Card Number:
(Please make sure you have 16 numbers for M/C, 13-16 numbers for VISA)
Expiration Date:
Please Confirm Amount:
Comments

Please note that in areas where Bedrosians has a physical presence, we will forward this sample request to our sales representative serving your area.

 

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