SAMPLE REQUEST FORM

SR. NO:
DOC NO: REV NO : EFFECTIVE DATE:
DATE OF REQUEST : 20.12.2018 REQUEST BY : MR. HAARISH

CUSTOMER NAME & IF, ANY SPECIAL REMARK / REASON

SR. NAME OF THE PRODUCT GRADE / CLASSIFICATION QUANTITY
LOCATION FOR SAMPLE

KHALID MOUMIN, For introducing product to new

1 MIRR TURBO DEO API CH-4 SAE 15W-40 1Ltr
SOMALIA customer

1Ltr "
2 MIRR TURBO PLUS API CI-4 SAE 15W-40 "
3 1Ltr "
MIRR X DEO API CF-4 SAE 15W-40 "
4 1Ltr "
MIRR X DEO API CF-4 SAE 50 "
1Ltr "
5 MIRR DEO API CF "
6 1Ltr "
MIRR HYDRAULIC OIL 68 AW "

DATE OF SAMPLE GIVEN & SIGN: SAMPLE RECEIVED BY :

(Q.C LABORATORY) DEPARTMENT :

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