Company Name       

Contact Name    

Address       City 

State/Province            Zip Code  -         

Phone            Fax 

Email Address   

Product Information:

Quantity to order       

Do you have a product which you would like to assimilate?  Yes No

If so, Please specify  

LIQUID: 

Type to be filled None Liquid Lotion Cream Gel Paste     Amount of fill per pouch grams ounces pounds  

Supplied by customer  None Yes No    

Powder:  

Type None Free Flowing Non-Free Flowing     Amount of fill per pouch grams ounces pounds

Supplied by customer None Yes No

Towel:    

Quantity per pouch  

Types  None Paper Nonwoven Stiff Card Flexible Card Cotton Tipped Swab Foam Tipped Swab Solid Object Other        Sizes  4 5 6 8 10 12 Other X  5.25 6 7.25 8 Other

Basis Weight  21 LB. Paper 1 oz./sq. yd Nonwoven 1.25 oz./sq. yd Nonwoven 2 oz./sq. yd. Nonwoven Other  

If other, Please specify

Supplied by customer  None Yes No

Film:        

Type  White Polyester Laminate Paper/Foil Laminate Clear Polyester Laminate Silver Polyester Laminate White Barex Laminate Other   

Pouch Size  1.25" 1.3" 1.625" 2.125" 2.5" 3.25" 5" 6.5" Other   X  2.5" 3" 3.5" 4" 4.5" 5" Other   If other, Please specify 

Perforation Cut  Yes No         Tear Notch  Yes No

 Supplied by customer  Yes No           

If film is to be supplied by customer, please provide the specifications: 

Print:       

Colors  1 2 3 4 Process Other   UV Varnish  No Yes

Supplied by customer  No Yes

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