SAMPLE REQUEST FORM

SR. NO:
DOC NO: REV NO : EFFECTIVE DATE:
DATE OF REQUEST : REQUEST BY :

SR. NAME OF THE PRODUCT GRADE / CLASSIFICATION QUANTITY CUSTOMER NAME & IF, ANY SPECIAL RE
LOCATION REASON FOR SA

5
DATE OF SAMPLE GIVEN & SIGN: SAMPLE RECEIVED BY :
(Q.C LABORATORY) DEPARTMENT :
 LITHIUM GREASE EP-3(BLUE) 500Gms of SECOND QUA

PECIAL REMARK /
N FOR SAMPLE
SECOND QUALITY