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Sample Request Form

Please provide the following shipping information: 
All shipments will be shipped UPS Ground unless otherwise noted. 

Please note fields marked with an * are required.

* Requestor Name:  
* Requestor Company:  
* Requestor Phone Number:
(eg +1 314 344 9300)
* Requestor Email Address:  
* Customer Contact Name:  
* Customer Phone Number:
(eg +1 314 344 9300)
* Shipping Address:
 
* City:
 
* US State or Country:  
* Postal/Zip Code:
 
Product Line:  
Industry:  
* OEM / End User:  
Project / Program Name:
(if applicable)
 
Preferred Shipping Method:  

All shipments will be shipped UPS Ground unless otherwise noted. 

Account #:  
Special Shipping remarks:       

Does your request have Military Requirements? Click Here.

All the following information MUST be completed on requests for any military industry/customers.
Requests missing any information below will be rejected.
 

Is Country of Origin information required?


Will this part be used in a controlled item (as defined by ITAR?)


Will a First Article/Source Inspection be required?


Will you require any certifications of manufacturers who are involved inthe production of this part?


Is this part required to be DFARS compliant?


Is this Department of Defense CAGE code required for production with this order?


Is a NADCAP approved supplier required for Heat Treat?


Is a NADCAP approved supplier required for Plating?

 

No Military Requirements? Click Here.


Does your request have Automotive Requirements? Click Here.

All the following information MUST be completed on requests for any automotive industry/customers.
Requests missing any information below will be rejected.
 

Testing Methods & Standards : (other than drawing or description)
Validation Plan:         First Article Inspection: 
Type : Internal    PPAP    VDA2    Level

System Requirements: (Quality Management System requirements, Targets, etc.) 

 

Environmental Requirements: RoHS    IMDS    REACH
  

No Automotive Requirements? Click Here.


 
Customer |
Part Number
(if applicable)
Rev Laird
Part Number
or Product
Description
Rev * Sample
Quantity
& UOM
* EAU
           
           
           
           
           
           
           
           
           
           

EAU = Estimated Annual Usage       UOM = Unit Of Measure