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Please answer the following questions. (Those marked with * are required.)

1. To which region of the world will the sample be sent?*	Asia-Pacific Europe, Middle East, Africa, or India North America or Latin America
2. From which product group do you want a sample?*	Indicate the specific product(s) below.*
	(example: AC 120)
Avalure® Film-forming Polymers
Carbopol® Rheology Modifiers
Fixate™ Hair Fixative Polymers
Guerbet Derivatives
Hydramol™ Esters
Lanolin and Lanolin Derivatives
Methyl Glucoside Derivatives
Novemer® Polymer
Pemulen® Primary Emulsifiers
Schercemol™ Esters
SilSense™ and Ultrabee® Specialty Silicones
Surfactants
Other
Your Contact Information
Your Name*
Your Phone Number*
Name of Your Company*
Your E-Mail Address*
Ship-To Address (line 1)*
Ship-To Address (line 2)
City*
State/Region*
Postal/Zip code*
Country*
Applications for the Sampled Product(s)*
The name of your contact at Lubrizol
Additional Comments
*Security Code	To verify that this is a valid request, please type the security code from the picture. If the code is illegible, click the "Regenerate" button to generate another one.