Sample Request Form - Diverse Electronics

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? *

Add 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: *
	Other:
Postal/Zip Code: *
Country: *
Phone: *
Website:
Are you a Distributor? *	Yes No
Will these items be resold? *	Yes No

All samples are processed at Diverse Electronics discretion.

Contact Permission

We want to email you exclusive offers and the latest information from our partners. We'll always treat your personal details with the utmost care and will never sell or share with third parties for marketing purposes. Please note, you may unsubscribe at any time.

Please let us know if you would like us to contact you by selecting one of the options below.

Yes please, I'd like to hear about offers and services.
No thanks, I don't want to hear about offers and services.

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