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Molex Sample Request Form
Samples Request
Enter your request for product samples below.
Please fill in all required fields.  * = required field
   Korean Sample Request

Requester First Name: * Requester E-mail: *
Requester Last Name: * Tel: *
Requester Company Name : * Fax:
  Industry: *
  Job Function: *
 
Ship To Company: *
Purchase Order (Not Required):
Attention To: *
Ship To Address Line 1: *

Every effort will be made to send the requested samples;
However, samples are subject to availability.

Since samples may not be representative of production quality,
they should not be used for customer production.

Ship To Address Line 2:
City: *
Zip/Postal Code: *
Ship To Country: *
State/Provinces for US and Canada: *

Quantity :  Part Number: 
Quantity :  Part Number: 
Quantity :  Part Number: 
Quantity :  Part Number: 
Quantity :  Part Number: 
Quantity :  Part Number: 

Note: If address contains a P.O. Box, Method of Shipment must be First Class Mail.
Method of Shipment: *   
Account to Charge:  You must enter your account number for FedEx, or UPS.
If you are currently buying Molex products, from whom do you buy: 

I have read and accepted the Molex .