2012 Event
Request for BLUE LIZARD Samples
**PLEASE
COMPLETE and RETURN VIA FAX or EMAIL.
If product is not available via pharmacies or physician office in your area then samples will be provided on a limited basis*
Four to six weeks notice prior to the event date is required. This form is not intended for monetary donations.
*Name of person completing application: _____________________________________________
*Office Name (Please Print Clearly): ________________________________________________
*Shipping Address: ______________________________________________________________
*City: ______________________________ State: ____________ Zip: _____________________
*Telephone: (______) _________________________Fax: (______) _______________________
*Email Address: _________________________________________________________________
Is this a Health Fair/Skin Cancer Screening? Y or N If yes, please provide the
name of the participating physician and/or nurse
____________________________
How/Where did you hear about BLUE LIZARD?
____________________________
Please list pharmacies in your area that stock BLUE LIZARD:
___________________________________________________________
*Name of Event:
___________________________
*Date of Event must be entered:
____________________________
*Expected Attendance: _______________________
Number of samples requested: ____________________
*Please
fax any event information that is available, i.e. fliers, brochures,
etc.
Please keep in mind that we do our best to accommodate all requests.
However, due to the tremendous demand for BLUE LIZARD, it is not
always possible. Please note that should your request be denied, we will do our best to notify you via email.
Thank you,
Del Ray Dermatologicals
phone: 1-800-877-8869 fax: 423-926-0165
email: customerservice@crownlaboratories.com