Sample Request Form

James S. Heaton Company's territory includes Northern California, Northern Nevada, and Hawaii. If you are outside of our territory, you should contact the manufacturer to find your local representative.

To receive samples from any of the manufacturers that James S. Heaton Co. represents, please fill out the form below. For more than one part, submit the form and then press Reset.

Name
Company
Address
 
City   State   Zip
Phone# E-mail
Manufacturer
Part Number   Quantity
Briefly describe the project or use for the sample.
Application
If the sample is used in production, how many will you likely use?
Potential
What other manufacturers are you considering for this part?
Competition