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* Company Website Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country 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 Phone*1. WHAT TYPE OF APPLICATION ARE YOU USING THE DYE/PIGMENT/LAKE IN?* Adhesive, solvent Adhesive, water Candle Cleaning product, liquid Cleaning product, powder Coating, water Coating, solvent Cosmetics Drug Epoxy Food Ink, Alcohol Ink, Solvent Ink, Water Leak tracing Oil/Water emulsion Petroleum based product Shampoo Wax Other Other 2. DO YOU NEED AN FDA CERTIFIED COLORANT?* Yes No 3.WHAT IS THE PRIMARY SOLVENT THAT YOU ARE USING?* Acetone Ethyl Alcohol Hydrochloric Acid Hydroxide Isopropyl Alcohol Kerosene Methyl Alcohol Mineral Spirits Naphtha Paraffin wax Styrene Sulphuric Acid Toluene Water Xylene Other Other 4. WHAT COLOR(S) DO YOU WANT?* Black Blue Brown Green Orange Pink Red Violet White Yellow Other Other (If using our Color Selector Tool, please copy/paste the HEX code here.) 5. WHAT IS THE APPROXIMATE PH OF YOUR PRODUCT? 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) CAPTCHAPhoneThis 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
