2008 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
samples will be provided on a limited basis***

Name of person completing application: _____________________________________________

Office Name (Please Print Clearly): ________________________________________________

Shipping Address: ______________________________________________________________

City: ______________________________ State: ____________ Zip: _____________________

Telephone: (______) _________________________Fax: (______) _______________________

Email Address: _________________________________________________________________

HOW/WHERE DID YOU HEAR ABOUT BLUE LIZARD? ____________________________

______________________________________________________________________________

LIST PHARMACIES IN YOUR AREA STOCKING BLUE LIZARD? ____________________

______________________________________________________________________________

Name of Event: ________________________________________________________________

*Please fax any event information that is available, i.e. fliers, brochures, etc.

Date of Event must be entered: _____________________________________________

Expected Attendance: ___________________Number of samples requested: _______________

We appreciate you. Please keep in mind that we do our best to accommodate all requests, but due to
the tremendous demand for BLUE LIZARD, it is not always possible to provide the quantities requested.

Thanks,
Rebecca A. Wells
rwells@crownlaboratories.com
Del Ray Dermatologicals
1-800-877-8869 Fax: 423-926-0165

FOR OFFICE USE ONLY: Samples quantity approved: _____________Initial: _____Date shipped: _____________