Sample Request Form: DuPont™ Capstone® Fluorosurfactants

A DuPont Technical Service Specialist will evaluate your desired performance characteristic and intended end-use application, and select the optimum Capstone® fluorosurfactant offering for your needs.

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Please complete the fields indicated below.

Please enter your first name.	Please enter your last name.
First Name*	Last Name*

	Please enter your company.
Title	Company*

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E-Mail Address*

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Street Address*

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City*	State/Province*

Please enter your postal/zip code.	Please select your country.
Postal Code/ZIP Code*	Country*

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Phone*	Fax

Please select Yes or No.

Will the samples or products be used in an agricultural, medical or personal care application?*

Yes No

Please select Yes or No.

Will samples be used at high temperature (>150°C)?*

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Please select Yes or No.

Will respirable particles be generated during the application (<10 microns)?*

Yes No

Please select Yes or No.

Will sample evaluation be done in a laboratory or controlled location?*

Yes No

Please select Yes or No.

Does your company follow documented safety procedures for handling and disposing of flammable or hazardous chemicals?*

Yes No

Do you intend to purchase from a distributor?

Yes No

Please choose a distributor name.

If yes, please specify the distributor:

Please select a performance characteristic.

What is the primary performance characteristic you desire from this sample for your application?*

If other, please specify:

Please select your intended end-use application.

What is the intended end-use application in which this sample will be used?*

If other, please specify:

How did you hear about DuPont™ Capstone®repellents and surfactants?

May we send you occasional eCommunications - including emails and newsletters - about DuPont™ Capstone® repellents and surfactants?

Yes, add me to your distribution list.

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