This is a form for customers to request a sample of a product to be sent to them by post.

Heading 4 (optional)

You can add more text here. There is no character limit, but be careful that the left and right halves of your form are somewhat even - the left containing text and an image, the right being the form. If you have an image it needs to be 960 px wide, but can be any height.

Bulleted list (optional)

• You can have bullet points
• Like these
• Or this can be an additional text field
• Or no additional section at all