Online Pharmaceutical Sample Ordering

Note:

If you have an Industrial application and food application for any of the materials listed, please go to the product specific website: www.methocel.com, www.ethocel.com, www.polyox.com. Thank you!

Controlled Release Sample Requests for North America (U.S., Canada and Puerto Rico)
Effective July 1, 2007 contact Colorcon at 215-699-7733 or visit Colorcon's web site for additional area contacts.

Please make a selection:

	Please help me in selecting a sample of one of your Dow excipients. If you are not sure what to select, simply complete and send this email request form.
	I am a current Dow customer and need an additional sample of Dow excipients. Need an additional sample of one of our Dow excipient products that you are currently using? To receive the additional sample you need for lab-scale work, simply complete and send this email request form.
Please note: Standard sample size is .25kg.

Email Form

First Name^‡

Last Name^‡

Company^‡

Title^‡

Address^‡

Address

City^‡

State/Province^‡

Zip/Postal^‡

Country^‡

Phone^‡

(Include Country/Area Code)

Fax

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Email^‡

To select multiple product options from the menus below, hold down the "Control" key on your keyboard ("Command" for Mac users).

Note: If you have an Industrial application for any of the materials listed, please go to the product specific website: www.methocel.com, www.ethocel.com, www.polyox.com. Thank you!

METHOCEL

1.
2.

ETHOCEL

1.
2.

POLYOX

1.
2.

Is your product going to be:

		Rx New
		Rx Generic
		OTC
		Nutritional
		Other

What is the delivery route?^‡

		Solid Dosage (tablets, capsules, controlled release)
		Liquid Oral Dosage
		Intranasal
		Topical/Transdermal
		Ophthalmics
		Other, please specify:

What stage of product
development are you in
with this product?

If other, please specify:

Do you influence the decision
to buy?

		Yes
		No

Additional questions
or comments

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