---
type: page
title: Sample Request
handle: sample-request
url: https://lead-glass-pro.myshopify.com/pages/sample-request
published_at: '2020-05-15T13:45:16.000Z'
---

  Sample Request <!-- @import (css) '@{buttonFontLink}'; .form-label-left{ width:150px; } .form-line{ padding-top:12px; padding-bottom:12px; } .form-label-right{ width:150px; } body, html{ margin:0; padding:0; background:#fff; } .form-all{ margin:0px auto; padding-top:0px; width:690px; color:#555 !important; font-family:"Lucida Grande", "Lucida Sans Unicode", "Lucida Sans", Verdana, sans-serif; font-size:14px; } .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{ color: false; } --> <!-- /\* Injected CSS Code \*/ .form-label.form-label-auto { display: block; float: none; text-align: left; width: 100%; } /\* Injected CSS Code \*/ --> // <!\[CDATA\[ JotForm.init(function(){ if (window.JotForm && JotForm.accessible) $('input\_21').setAttribute('tabindex',0); if (window.JotForm && JotForm.accessible) $('input\_22').setAttribute('tabindex',0); if (window.JotForm && JotForm.accessible) $('input\_23').setAttribute('tabindex',0); if (window.JotForm && JotForm.accessible) $('input\_14').setAttribute('tabindex',0); JotForm.newDefaultTheme = false; JotForm.alterTexts({"couponApply":"Apply","couponBlank":"Please enter a coupon.","couponChange":"","couponEnter":"Enter coupon","couponExpired":"Coupon is expired. Please try another one.","couponInvalid":"Coupon is invalid.","couponValid":"Coupon is valid.","shippingShipping":"Shipping","taxTax":"Tax","totalSubtotal":"Subtotal","totalTotal":"Total"}, true); /\*INIT-END\*/ }); JotForm.prepareCalculationsOnTheFly(\[null,{"name":"sampleRequest","qid":"1","text":"Sample Request","type":"control\_head"},{"name":"name","qid":"2","text":"Name","type":"control\_fullname"},{"name":"email3","qid":"3","text":"E-mail","type":"control\_email"},{"name":"addressTo4","qid":"4","text":"Address to Send the Sample","type":"control\_address"},{"name":"contactNumber","qid":"5","text":"Contact Number","type":"control\_phone"},null,null,null,null,null,null,null,{"name":"submit","qid":"13","text":"Submit Request","type":"control\_button"},{"name":"specialInstructions","qid":"14","text":"Special Instructions","type":"control\_textarea"},null,null,null,null,null,null,{"description":"","name":"companyName","qid":"21","subLabel":"","text":"Company Name","type":"control\_textbox"},{"description":"","name":"quoteNumber22","qid":"22","subLabel":"Enter your quote number or job name","text":"Quote Number or Project Name","type":"control\_textbox"},{"description":"","name":"leadEquivalency","qid":"23","subLabel":"","text":"Lead Equivalency","type":"control\_textbox"}\]); setTimeout(function() { JotForm.paymentExtrasOnTheFly(\[null,{"name":"sampleRequest","qid":"1","text":"Sample Request","type":"control\_head"},{"name":"name","qid":"2","text":"Name","type":"control\_fullname"},{"name":"email3","qid":"3","text":"E-mail","type":"control\_email"},{"name":"addressTo4","qid":"4","text":"Address to Send the Sample","type":"control\_address"},{"name":"contactNumber","qid":"5","text":"Contact Number","type":"control\_phone"},null,null,null,null,null,null,null,{"name":"submit","qid":"13","text":"Submit Request","type":"control\_button"},{"name":"specialInstructions","qid":"14","text":"Special Instructions","type":"control\_textarea"},null,null,null,null,null,null,{"description":"","name":"companyName","qid":"21","subLabel":"","text":"Company Name","type":"control\_textbox"},{"description":"","name":"quoteNumber22","qid":"22","subLabel":"Enter your quote number or job name","text":"Quote Number or Project Name","type":"control\_textbox"},{"description":"","name":"leadEquivalency","qid":"23","subLabel":"","text":"Lead Equivalency","type":"control\_textbox"}\]);}, 20); // \]\]>

  

*   Name
    
     First Name Last Name
    
*   Company Name
    
*   E-mail
    
*   Contact Number
    
     \- Area Code Phone Number
    
*   Address to Send the Sample
    
     Street Address
    
     Street Address Line 2
    
     City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming State
    
     Zip Code
    
*   Quote Number or Project Name
    
     Enter your quote number or job name
    
*   Lead Equivalency
    
*   Special Instructions
    
*   Submit Request
    
*   Should be Empty: