Date request made: _____________________

Date samples needed by: ________________

Project Designation (for your reference): _______________________________________

Your Name: _________________________________________________________________

Company Name: _____________________________________________________________

Address: ___________________________________________________________________

City, State, Zip: _____________________________________________________________

Phone: _________________ Fax: ____________________________

E-mail: __________________ Web site: _______________________

Please send the following Permitex samples:

Standard set of samples for our evaluation: ________.

Custom set of samples for our evaluation: ________.

If you have chosen a custom set of samples, please provide us with the following color choice information. You may chose from any major paint manufacturers color deck. Please write the name / number of your choice below.

Types of finishes:

Smooth Coat over Texture: Color #____________________________
(Note: This results in a single color sample. Reference paint chip # and name of national manufacturer).

Texture over Smooth Coat:
(Note: The texture coat is in the foreground over a smooth coat background. You may select the same color or choose different colors for each coat. You can select more than one texture color to achieve a stipple effect. Only one color for the smooth coat may be selected).

Texture Color(s): ________________________. Smooth Color: _________________________.
(Reference paint chip # and name of national manufacturer).

Special Requests: _____________________________________________________________

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