SAMPLE REQUEST FORM Please use this form to aid our Support team in identifying thebest materials for you to evaluate. "*" indicates required fields Name* First Last Email* Title Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone1. WHAT TYPE OF APPLICATION ARE YOU USING THE DYE/PIGMENT/LAKE IN?* Adhesive, solvent Drug Petroleum based product Cleaning product, powder Coating, water Cosmetics Oil/Water emulsion Cleaning product, liquid Ink, Alcohol Ink, Water Leak tracing Candle Food Coating, solvent Wax Adhesive, water Epoxy Shampoo Ink, Solvent Other Other 2. DO YOU NEED AN FDA CERTIFIED COLORANT?* Yes No 3.WHAT IS THE PRIMARY SOLVENT THAT YOU ARE USING?* Acetone Naphtha Methyl Alcohol Kerosene Mineral Spirits Xylene Paraffin wax Sulphuric Acid Toluene Ethyl Alcohol Hydrochloric Acid Styrene Water Isopropyl alcohol Hydroxide Other Other 4. WHAT COLOR(S) DO YOU WANT?* Black Red Yellow Pink Brown Orange White Violet Blue Green Other Other (If using our Color Selector Tool, please copy/paste the HEX code here.) 5. WHAT IS THE APPROXIMATE PH OF YOUR ? 6. ARE THERE ANY HARSH CHEMICALS IN YOUR PRODUCT?* None Bleach D-Limonene Hydrogen Peroxide Other oxidizers Chlorine Lye Other Other 7. DYE CURRENTLY USED IN THIS PRODUCT (IF ANY, AND DOES THIS DYE WORK) 8. DYE DESIRED TO BE USED IN THIS PRODUCT (IF ANY IS IDENTIFIED) PhoneThis field is for validation purposes and should be left unchanged. Δ HOME OUR PRODUCTS SERVICE AND SUPPORT PYLAM VALUE CONTACT US Location Pylam Products Company, Inc.2175 East Cedar Street, Tempe, Arizona 85281-7431 Phone: 480-929-0070Toll-Free: 800-645-6096Fax: 480-929-0078 Need a Sample Request a sample below CLICK HERE
