Sample Request Form

Sample Request Form

In order to receive samples, please fill out the sample request form below and submit. Once received, our Compliance team will review the request. Please allow up to 3 business days for the Compliance team to review. However, depending on the request and the level of detail required, it may take longer to review.

File Attachments

Non-profit request - please provide 501c3 for charity. Consumer tasting event - please provide event flyer and/or additional supporting marketing materials.

Drag and drop files here or

Supplier Name*

Company name as it appears on Park Street Navigator Platform

Submission Date*

Submitted By*

Please include your first and last name, and position within the company

Email Address*

Please provide the email address of the person submitting/responsible for the request.

Purpose of Samples*

Please select the primary purpose for this sample request. If other is selected, please provide full event details below.

Select or enter value

Event Details

If you have any additional relevant details for the event, please include in this section.

Event Details - Who is pouring at the event?*

Please provide the specific names (first and last) of the person(s) pouring at the event.

Event Details - Expected Attendees*

Select or enter value

Product Codes Needed for Samples*

Please include how many bottles or cases you would like of each product. Product Code(s) can be found in the Products Management tool within the Operations Module on Navigator.

Market*

Please select the state where the samples will be poured/consumed.

Select or enter value

Venue Name*

Venue License Number

Please provide venue license if available.

Ship To Address*

Please include full delivery address including ATTN and/or other delivery requirements.

Delivery Date***

Please select the date that the samples are required to be delivered by.

Delivery Method*

Select or enter value

Venue Contact Person*

Please provide the primary contact for the person receiving the shipment.

Venue Email Address*

Please provide the customer e-mail address so that an invoice can be sent.

Venue Phone Number*

Special Instructions

Please provide any special instructions or additional notes in this area. (i.e. retailer operating hours, delivery times, self-delivery etc.) Park Street will do its best to accommodate any special delivery windows placed, however these windows cannot be guaranteed.

Sample Acceptance*

In order to receive samples, I understand that I must possess a Park Street Imports, LLC (hereinafter referred to as “PSI”) salesperson/solicitor permit, or be an approved provider with Omnia Marketing in the state in which I will be receiving samples and must also have a current and fully-executed salesperson acknowledgement agreement on file. I further understand that sample inventory pulled from any PSI warehouse or shipped to my attention, as a brand agent/salesperson, must be used pursuant to the terms of such salesperson acknowledgement agreement. By accepting delivery of any samples from PSI, I assume all liability for non-compliance with any state statute, regulation, and rule within any state(s) where I use samples. I, along with my employer, will be liable for any and all damages incurred by PSI including the loss of business, loss of potential business, any fines and any re-submission fees, attorney’s fees, and any and all other damages incurred. I further understand that it is both the responsibility of the Brand Owner, whose product(s) I am soliciting orders for, and my responsibility to ensure compliance with my agreement and that my failure to do so may result in PSI terminating my ability to act as a salesperson and my company’s ability, as a client, to receive samples. If I do not immediately refuse delivery, I recognize that I am deemed to have accepted delivery. Please check below box acknowledging your acceptance of the sample request terms.

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