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Request Samples

Sample Request Form

Thank you for your interest in requesting samples. No-charge samples are available for testing/review purposes for qualified applications. To determine if your application qualifies, please complete and submit the form below.

* required field

Please enter the following information for each item(s) you are interested in:

Part No. and/or Description: *
Manufacturer: *
Sample Quantity: *
Potential Order Quantity: *
When will you be ordering this item? *

Additional Information and/or Sample Reason:

Please enter the shipping address you would like sample(s) sent:

Name: *
Title: *
Company: *
Email: *
Address Line 1: *
Address Line 2:
City: *
Province/State: *
Postal/Zip Code: *
Country: *
Phone: *
Are you a Distributor? * Yes No
Will these items be resold? * Yes No

All samples are processed at Diverse Electronics discretion.

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