Product Information Form

Kindly fill in the following form for more information on Valia Chemicals and its products:

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail

Nature Of Business :

Please indicate your options by checking the relevant boxes:

Product	Sample	Price	C.I. Number
Naphthols	Sample	Price
Fast Bases	Sample	Price
Direct Dyes	Sample	Price
Vat Dyes	Sample	Price
Acid Dyes	Sample	Price
Basic Dyes	Sample	Price
Solvent Dyes	Sample	Price
Mordent Dyes	Sample	Price
Disperse Dyes	Sample	Price
Pigment Powders	Sample	Price
Optical Brightening Agents	Sample	Price
Dye Intermediates	Sample	Price	Products
Any Other Product	Sample	Price

Please arrange to send us:
Product Brochure, and / or
Shade Card

Some of the leading end-user industries serviced by us are (please check whichever is applicable):

Leather Paints Textiles Ink Plastics Paper Other