Carrubba: Sample Request Profile

SAMPLE REQUEST PROFILE

Please make your selection from the following product categories:	Flavor Fragrance Botanical Extract Natural Aromatic Extract DeoPlex Essential Waters
Fragrance, Flavor, Natural Aromatic Extract or Essential Water? Please provide a short character description of the product(s) you desire.
Price range?
Botanical Extract? Please list the extract(s) you desire.
If more than one, may we blend them for you?	Yes No
Botanical Extract Base:	PG/Water BG/Water Soybean Oil Sunflower Oil Glycerin Other (specify)
Paraben Free?	Yes No
Please provide a description of the product(s) to which this will be added.
Is your product?	Oil Soluble Water Soluble
Can you send us a sample of your base?	Yes No
Anticipated order requirements
Your company's approximate total $ annual consumption of chosen category?
Company Information
Company Name:
Company Address:
Company Contact:
Telephone Number:
Fax Number:
Email Address:
Website:
Type of Business:	Marketer Contract Mfg. Consultant Re-Seller Other (specify)
How did you hear about Carrubba?
Have we sampled you in the past?	Yes No