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Sales Person
(Required)
Zahin
Ikin
Diana
Aisyah
Sample Request Date
(Required)
DD slash MM slash YYYY
Customer Name
(Required)
Title
Tuan
Puan
Encik
Cik
Tan Sri
Puan Sri
Datuk
Dato
Datin
Prof.
Dr.
Ir.
Prefix
First
Company Name
(Required)
Company Code (if any)
Sample Request Type
(Required)
New Request
Revise Sample
Amendment
Sample Reference Code
(Required)
Sample Type
(Required)
Amendment for New Sample Request
Amendment for Revise Sample Request
Amendment Request for Sample Development
(Required)
List of Requested Sample Revision
(Required)
Changes Required
Specific Value/ Description
Add
Remove
Sample Mark (Description)
(Required)
Product Type
(Required)
Liquid Bottle
Liquid Sachet
Liquid Pouch (RTD)
Jelly Sachet
Jelly Pouch (RTD)
Powder Sachet
Powder Bottle
Intended Function List
(Required)
Add
Remove
Flavor
(Required)
Volume Per Intake (insert gm/ml)
(Required)
Volume Per Bottle (insert gm/ml)
(Required)
Sachets Per Box
(Required)
Requested Ingredients/ Specifications
(Required)
Has any Sample Reference as benchmark?
(Required)
Yes
No
Upload Sample Reference Photo
(Required)
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Select files
Max. file size: 512 MB.
