Personal Care Sample Request Form

If you need information about Rohm and Haas Personal Care products and services, please fill out the form below and provide as much detail as possible about your information needs and we will direct it to the appropriate Rohm and Haas representative.

These materials are ingredients intended for the formulation of Personal Care Products and therefore will be sampled only to laboratories or manufacturing sites engaged in the research, testing or manufacture of Personal Care Products.

All contact information will be kept confidential.

*Required fields

Name:*
Title:*
Company Name:*
Email Address:*
Confirm Email Address:*
Street Address — Line 1:
Street Address — Line 2:
City:
State/Province:
Postal Code:
Country:*
Phone Number:*
Fax Number:
Are you currently serviced
by our distributor? 		Yes      No
Are you a customer already?  

Product #1*:
   
Application and Potential 
Volume for Product #1:
   

Product #2:
   
Application and Potential
Volume for Product #2: