purchasers name:  *

address:  *

city:  *     state:  *     zip:  *

country: 

phone:  *     e-mail: *

e-mail address will only be used to send a confirmation of your sample request.

retailer information

company name:  

address:  

city:       state:       zip:  

country: 

phone:  

product information

product purchased:     

    indusparquet® 3/4" solid     face size:    3"     5 1/2"

    Antiquity™ hand-scraped     face size:    5"

    indusparquet® 7/16" solid   face size:    2 5/8"

    indusparquet® 5/16" solid   face size:    3 1/8"

    casanova engineered            face size:    4"

    triângulo® engineered            face size:    3 1/4"

    br-111™ engineered              face size:    3"     6 1/4"

other  
 
species purchased:  

purchase date:  

total square feet:  


type of installation:        nail        staple        glue        float

  
rooms installed (check all that apply):
       

foyer	dining room	bedroom
family room	kitchen	bathroom
living room	den/office	basement

please check one:

   new construction                    remodel