Sample Request Form

Samples are the easiest way for you to evaluate our products. To request a sample simply provide us with the part number you require and fill in your details below. Our sales support staff will happily process your request.

Sample(s) will be provided  free of charge where possible, though may carry a $15.00 for Freight and Handling fee if we are unable add the samples onto the end of a open purchase order.  For this reason and to enable your system and ours to track traceability,  your sample request needs to have a PO number and be made through your official Purchase Order system.  

First Name*                        Last Name*
Job Title*                     Job Function*
Company*               Acct# if known
Address 1*
Address 2*                   City*
State*Postal Code*Country
Telephone*                                    Fax
Email*
Products Requested X-On Part Number* iCode Numb         Qty  Description *    
             
           
           
Application Telcom Consumer
  Computer Industrial
Network Other 
Potential Production Quantity Near Term* Long Term* First Buy Date*
Parts per Board*    Project Name*
*Urgent Sample Shipping $15.00 fee applies Purchase Order number for these samples*   
Our PO to cover this free sample order has been posted/emailed/faxed/Other
Comments or Action
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For more information on the various services that X-On offer, contact us today.