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class="container"><div role="navigation" aria-label="Breadcrumbs" class="breadcrumb-trail breadcrumbs" itemprop="breadcrumb"><ul class="trail-items" itemscope itemtype="http://schema.org/BreadcrumbList"><meta name="numberOfItems" content="2" /><meta name="itemListOrder" content="Ascending" /><li itemprop="itemListElement" itemscope itemtype="http://schema.org/ListItem" class="trail-item trail-begin"><a href="https://nissanchem-usa.com" rel="home"><span itemprop="name">Home</span></a><meta itemprop="position" content="1" /></li><li itemprop="itemListElement" itemscope itemtype="http://schema.org/ListItem" class="trail-item trail-end"><span itemprop="name">Sample Requests</span><meta itemprop="position" content="2" /></li></ul></div></div></div> <div id="content" class="site-content"><div class="container"><div class="inner-wrapper"> <script type= "text/javascript" src = "https://nissanchem-usa.com/wp-content/themes/biosocket-one/js/countries.js"></script> <style> .nope{display: none;} /* Style the form */ #sampleForm { min-width: 300px; padding-left:1em; border-left: 1em solid #21b8c5; } /* Style the input fields */ input[type='text']{ width: 100%; } input[type='checkbox'],input[type='radio'] { margin-right:.5em; } .wrapCont{ width:100%; height:100%; overflow-y: auto; margin:1em 0; display: flex; flex-wrap: wrap; justify-content: space-between; } .wrapCont label{ width: 300px; margin:0 1em 1em 0; } /* Mark input boxes that gets an error on validation: */ .invalid { background-color: #ffdddd; } .icon-warning:after{ content: '\f071'; font-family: 'Font Awesome 5 Free'; font-weight: 900; color:#ccc; margin-left: .5em; } /* Hide all steps by default: */ .tab { display: none; } /* Make circles that indicate the steps of the form: */ .step { height: 15px; width: 15px; margin: 0 2px; background-color: #bbbbbb; border: none; border-radius: 50%; display: inline-block; opacity: 0.5; } /* Mark the active step: */ .step.active { opacity: 1; } /* Mark the steps that are finished and valid: */ .step.finish { background-color: #21b8c5; } @keyframes fadeIt { 0% { background-color: #ffdddd; } 100% { background-color: #FFFFFF; } } .fadeout{ animation: fadeIt 5s ease-in-out; } </style> <script type="text/javascript"> function validate_form(thisform,addNote){ with (thisform){ /*getQuote(addNote);*/ } } var hazTotal=0; var nonHazTotal=0; function getQuote(addNote){ //validate_form(document.forms["sampleForm"]); hazTotal=0; nonHazTotal=0; jQuery("#select5 option:selected").each(function(i){ if(jQuery(this).attr('class')=='haz'){ hazTotal=hazTotal+1; } else{ nonHazTotal=nonHazTotal+1; } }); if(hazTotal>0){ //document.getElementById("shipMethod").value = "PRIORITY_OVERNIGHT"; document.getElementById("prioMsg").style.display="block"; jQuery('#shipMethod').val('PRIORITY_OVERNIGHT').prop({selected: true}); } if(hazTotal+nonHazTotal==0){ alert('You must select at least one sample to calculate a shipping estimate.'); return; } document.getElementById("loadingImg").style.display="block"; var xmlhttp; if(window.XMLHttpRequest){// code for IE7+, Firefox, Chrome, Opera, Safari xmlhttp=new XMLHttpRequest(); } else{// code for IE6, IE5 xmlhttp=new ActiveXObject("Microsoft.XMLHTTP"); } xmlhttp.onreadystatechange=function(){ if(xmlhttp.readyState==4 && xmlhttp.status==200){ document.getElementById("loadingImg").style.display="none"; document.getElementById("shippingEstimate").innerHTML=xmlhttp.responseText; if(addNote==1){ /*Add shipping estimate to textarea2*/ textarea2.value=textarea2.value + "\nShipping estimate: " + document.getElementById("shippingEstimate").innerHTML; } } /*else{ document.getElementById("shippingEstimate").innerHTML=xmlhttp.responseText; }*/ } var sPath = window.location.pathname; sPath = encodeURI(sPath); xmlhttp.open("GET","https://nissanchem-usa.com/fedex/Rate/RateWebServiceClient.php?Street="+encodeURI(document.getElementById('street').value)+"&City="+encodeURI(document.getElementById('city2').value.trim())+"&State="+encodeURI(document.getElementById('state').value)+"&Zip="+encodeURI(document.getElementById('zip2').value.trim())+"&Country="+encodeURI(document.getElementById('country').value)+"&shipMethod="+document.getElementById('shipMethod').value+"&pm="+document.getElementById('paymentMethod').value+"&nonHazTotal="+nonHazTotal+"&hazTotal="+hazTotal,false); xmlhttp.send(); } </script> <div id="primary" class="content-area"> <main id="main" class="site-main" role="main"> <div class="entry-content"> <form method="POST" action="/check.php" onSubmit="return validate_form(this)" id="sampleForm"> <input type=hidden name="oid" value="00D300000000YZM"> <input type=hidden name="retURL" value="https://nissanchem-usa.com/thank-you/"> <div class="tab"> <p>Please fill out the following form to request additional information or samples of our products.</p> <h3>Contact Information</h3> <p> <select id="salutation" name="salutation"> <option value="" selected>Salutation</option> <option value="Mr.">Mr.</option> <option value="Ms.">Ms.</option> <option value="Mrs.">Mrs.</option> <option value="Dr.">Dr.</option> <option value="Prof.">Prof.</option> </select> </p> <p class="nope"> <input type="text" name="fullName" id="fullName" placeholder="Full Name"> </p> <p> <input type="text" name="name" id="name" class="nope"> <input class="req" oninput="this.className='req'" maxlength="40" type="text" id="first_name" size="20" name="first_name" placeholder="First Name (Required)"> </p> <p> <input class="req" oninput="this.className='req'" maxlength="40" type="text" id="last_name" size="20" name="last_name" placeholder="Last Name (Required)"> </p> <p> <input maxlength="80" type="text" id="title" size="20" name="title" placeholder="Title"> </p> <p> <input maxlength="80" type="text" id="company" size="20" name="company" placeholder="Company"> </p> <p> <input maxlength="80" type="text" id="URL2" size="20" name="URL" placeholder="Web Site"> </p> <p> <input class="req" oninput="this.className='req'" maxlength="80" type="text" id="email" size="20" name="email" placeholder="Email (Required)"> </p> <p> <input class="req" oninput="this.className='req'" maxlength="40" type="text" id="phone" size="20" name="phone" placeholder="Phone (Required)"> </p> <p> <input maxlength="40" type="text" id="fax" size="20" name="fax" placeholder="Fax"> </p> </div> <div class="tab"><h3>Request Type</h3> <select title="Request Type" id="requestType" name="00N300000013PQn" style="max-width:250px" class="req" onclick="this.className='req'"> <option value="" selected>Request Type (Required)</option> <option value="Sample Request - Commercial">Sample Request - Commercial</option> <option value="Sample Request - University">Sample Request - University</option> <option value="General Enquiry">General Enquiry</option> </select> <h4>Application</h4> <p>Select technologies of interest:</p> <div class="wrapCont"> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Adhesive Application">Adhesive Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Anti-Corrosion">Anti-Corrosion</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Anti-Static">Anti-Static</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Architectural Coatings">Architectural Coatings</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Automotive Coatings">Automotive Coatings</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Catalyst - Automotive">Catalyst - Automotive</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Catalyst - Chemical/Refining">Catalyst - Chemical/Refining</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="CMP Application">CMP Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Coil Coatings">Coil Coatings</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Cosmetic Application">Cosmetic Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Display Coatings">Display Coatings</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Electrical Coating Component">Electrical Coating Component</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Electro-Conductive">Electro-Conductive</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Filling/Binding Applications">Filling/Binding Applications</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Frictionizing Applications">Frictionizing Applications</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="General Industrial Coatings">General Industrial Coatings</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Glass Coating">Glass Coating</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Heat Transfer Foils">Heat Transfer Foils</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="High Temperature Application">High Temperature Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Holographic Applications">Holographic Applications</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Imaging Applications">Imaging Applications</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Ink Jet Application">Ink Jet Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Insulating Applications">Insulating Applications</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Investment Casting - High End">Investment Casting - High End</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Investment Casting - Low End">Investment Casting - Low End</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="IR Coating">IR Coating</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Medical Research Application">Medical Research Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Ophthalmic Coatings">Ophthalmic Coatings</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Paint Application">Paint Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Pharmaceutical Application">Pharmaceutical Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Printing Application">Printing Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Release Agent Application">Release Agent Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Thermal Imaging">Thermal Imaging</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Toner/Printing Application">Toner/Printing Application</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="UV Coating">UV Coating</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Window Films">Window Films</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Wood/Floor Coatings">Wood/Floor Coatings</label> <label><input type="checkbox" id="00N300000013sKt[]" name="00N300000013sKt[]" value="Undisclosed Application">Undisclosed Application</label> </div> </div> <div class="tab"><h3>Sample Selection</h3> <p>Select up to three products of interest:</p> <div onclick="countSamples()" class="wrapCont"> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="General Enquiry">General Enquiry</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ALUMINASOL - AS-200">ALUMINASOL - AS-200</label>  <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="EnduraSol - EPC 7540">EnduraSol - EPC 7540</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="EnduraSol - OXA 7540">EnduraSol - OXA 7540</label> <label class='icon-warning'><input class='haz' type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="EnduraSol - IBOA 1250">EnduraSol - IBOA 1250</label> <label class='icon-warning'><input class='haz' type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="EnduraSol - TCDDA 1250">EnduraSol - TCDDA 1250</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="EnduraSol - EOTMPTA 1250">EnduraSol - EOTMPTA 1250</label> <label class='icon-warning'><input type="checkbox" class='haz' id="00N300000013jAL[]" name="00N300000013jAL[]" value="EnduraSol - EOPETA 1250">EnduraSol - EOPETA 1250</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="EnduraHSP - 45">EnduraHSP - 45</label><label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="Lithium Silicate - LSS 35">Lithium Silicate - LSS 35</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="Lithium Silicate - LSS 45">Lithium Silicate - LSS 45</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="Lithium Silicate - LSS 75">Lithium Silicate - LSS 75</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="Melamine Cyanurate - MC-4500">Melamine Cyanurate - MC-4500</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="Melamine Cyanurate - MC-6000">Melamine Cyanurate - MC-6000</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" class='haz' value="NanoUse - ZR-OZ-S30M">NanoUse - ZR-OZ-S30M</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - DMAC-ST">ORGANOSILICASOL - DMAC-ST</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - DMAC-ST-ZL">ORGANOSILICASOL - DMAC-ST-ZL</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" class='haz' value="ORGANOSILICASOL - EAC-ST">ORGANOSILICASOL - EAC-ST</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - EG-ST">ORGANOSILICASOL - EG-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - DMAC-ST" class='haz'>ORGANOSILICASOL - DMAC-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - EG-ST" class='haz'>ORGANOSILICASOL - EG-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - DMAC-ST" class='haz'>ORGANOSILICASOL - DMAC-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - EG-ST" class='haz'>ORGANOSILICASOL - EG-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - IPA-ST" class='haz'>ORGANOSILICASOL - IPA-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - IPA-ST-L" class='haz'>ORGANOSILICASOL - IPA-ST-L</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - IPA-ST-UP" class='haz'>ORGANOSILICASOL - IPA-ST-UP</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - IPA-ST-ZL" class='haz'>ORGANOSILICASOL - IPA-ST-ZL</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MA-ST" class='haz'>ORGANOSILICASOL - MA-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-AC-2140-Z" class='haz'>ORGANOSILICASOL - MEK-AC-2140-Z</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-AC-4130-Y" class='haz'>ORGANOSILICASOL - MEK-AC-4130-Y</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-AC-5140-Z" class='haz'>ORGANOSILICASOL - MEK-AC-5140-Z</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-EC-2130-Y" class='haz'>ORGANOSILICASOL - MEK-EC-2130-Y</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-AC-2202" class='haz'>ORGANOSILICASOL - MEK-AC-2202</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-AC-4101" class='haz'>ORGANOSILICASOL - MEK-AC-4101</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-AC-5101" class='haz'>ORGANOSILICASOL - MEK-AC-5101</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-EC-2102" class='haz'>ORGANOSILICASOL - MEK-EC-2102</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-ST" class='haz'>ORGANOSILICASOL - MEK-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-ST-40" class='haz'>ORGANOSILICASOL - MEK-ST-40</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-ST-L" class='haz'>ORGANOSILICASOL - MEK-ST-L</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-ST-UP" class='haz'>ORGANOSILICASOL - MEK-ST-UP</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MEK-ST-ZL" class='haz'>ORGANOSILICASOL - MEK-ST-ZL</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MIBK-AC-2140-Z" class='haz'>ORGANOSILICASOL - MIBK-AC-2140-Z</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MIBK-EC-2130-Y" class='haz'>ORGANOSILICASOL - MIBK-EC-2130-Y</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MIBK-EC-2430-Z" class='haz'>ORGANOSILICASOL - MIBK-EC-2430-Z</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MIBK-SD" class='haz'>ORGANOSILICASOL - MIBK-SD</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MIBK-SD-L" class='haz'>ORGANOSILICASOL - MIBK-SD-L</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MIBK-ST" class='haz'>ORGANOSILICASOL - MIBK-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MIBK-ST-L" class='haz'>ORGANOSILICASOL - MIBK-ST-L</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - MT-ST" class='haz'>ORGANOSILICASOL - MT-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - NBAC-ST" class='haz'>ORGANOSILICASOL - NBAC-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - NPC-ST-30" class='haz'>ORGANOSILICASOL - NPC-ST-30</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - PGM-AC-2140-Y" class='haz'>ORGANOSILICASOL - PGM-AC-2140-Y</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - PGM-AC-4130-Y" class='haz'>ORGANOSILICASOL - PGM-AC-4130-Y</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - PGM-ST" class='haz'>ORGANOSILICASOL - PGM-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - PGM-ST-UP" class='haz'>ORGANOSILICASOL - PGM-ST-UP</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - PMA-ST" class='haz'>ORGANOSILICASOL - PMA-ST</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="ORGANOSILICASOL - TOL-ST" class='haz'>ORGANOSILICASOL - TOL-ST</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - MP-1040">SNOWTEX - MP-1040</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - MP-1040-H">SNOWTEX - MP-1040-H</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - MP-2040">SNOWTEX - MP-2040</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-20L">SNOWTEX - ST-20L</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-30">SNOWTEX - ST-30</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-30LH">SNOWTEX - ST-30LH</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-40">SNOWTEX - ST-40</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-50">SNOWTEX - ST-50</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-AK">SNOWTEX - ST-AK</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-AK-ML">SNOWTEX - ST-AK-ML</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-C">SNOWTEX - ST-C</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-N">SNOWTEX - ST-N</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-N30C">SNOWTEX - ST-N30C</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-N40">SNOWTEX - ST-N40</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-NS">SNOWTEX - ST-NS</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-N-XS">SNOWTEX - ST-N-XS</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-HS-M-20">SNOWTEX - ST-HS-M-20</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-O">SNOWTEX - ST-O</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-O40">SNOWTEX - ST-O40</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-OL">SNOWTEX - ST-OL</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-OL28">SNOWTEX - ST-OL28</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-OL40">SNOWTEX - ST-OL40</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-OS">SNOWTEX - ST-OS</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-OUP">SNOWTEX - ST-OUP</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-OXS">SNOWTEX - ST-OXS</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-OZL">SNOWTEX - ST-OZL</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-PS-M">SNOWTEX - ST-PS-M</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-PS-MO">SNOWTEX - ST-PS-MO</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-PS-S">SNOWTEX - ST-PS-S</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-S">SNOWTEX - ST-S</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-SB">SNOWTEX - ST-SB</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-UP">SNOWTEX - ST-UP</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-XL">SNOWTEX - ST-XL</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-YL">SNOWTEX - ST-YL</label> <label><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="SNOWTEX - ST-ZL">SNOWTEX - ST-ZL</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-G" class='haz'>TEPIC-G</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-S" class='haz'>TEPIC-S</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-SP" class='haz'>TEPIC-SP</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-SS" class='haz'>TEPIC-SS</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-HP" class='haz'>TEPIC-HP</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-L" class='haz'>TEPIC-L</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-PAS" class='haz'>TEPIC-PAS</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-UC" class='haz'>TEPIC-UC</label> <label class='icon-warning'><input type="checkbox" id="00N300000013jAL[]" name="00N300000013jAL[]" value="TEPIC-VL" class='haz'>TEPIC-VL</label> </div> <p><span class="icon-warning" style="margin-left:-0.5em"></span> Hazardous samples must be shipped using priority services.</p> </div> <div class="tab"><h3>Address</h3> <p> <input name="street" class="req" oninput="this.className='req'" id="street" type="text" placeholder="Street Address (Required)"> </p> <p> <input maxlength="40" class="req" oninput="this.className='req'" type="text" id="city2" size="20" name="city" placeholder="City (Required)"> </p> <p> <select id="state" class="req" oninput="this.className='req'" name="state"></select> </p> <p> <input class="req" oninput="this.className='req'" maxlength="20" type="text" id="zip2" size="20" name="zip" placeholder="Zip Code (Required)"> </p> <p> <select onchange="print_state('state',this.options[this.selectedIndex].text);" id="country" name="country"> <option value="US" selected>USA</option> <option value="CA">Canada</option> <option value="MX">Mexico</option> <option>--------</option> <option value="BZ">Belize</option> <option value="CR">Costa Rica</option> <option value="SV">El Salvador</option> <option value="GT">Guatemala</option> <option value="HN">Honduras</option> <option value="NI">Nicaragua</option> <option value="PA">Panama</option> </select> </p> </div> <div class="tab" id="lastTab"><h3>Payment</h3> <p><i style="font-weight:normal">We only accept FedEx Accounts for payment and shipping.</i></p> <p> <input type=hidden title="Shipping / Payment Method" id="paymentMethod" value="FedEx Account" name="00N300000013QQ5" readonly > <input oninput="this.className='req'" maxlength="25" type="text" id="CCNumber" size="20" name="00N300000013QNW" autocomplete="off" placeholder="FedEx Account Number (Required)"> </p> <p> </p> <p> <textarea maxlength="255" type="text" wrap="soft" id="textarea2" name="00N300000013QSp" placeholder="Special Shipping Instructions"></textarea> </p> <p>Shipping Method:</p> <p> <select id="shipMethod" name="shipMethod" oninput="this.className='req'"> <option value="PRIORITY_OVERNIGHT">Priority Overnight</option> <option value="FEDEX_EXPRESS_SAVER" selected>Express Saver</option> <option value="FEDEX_GROUND">Ground</option> <option value="INTERNATIONAL_ECONOMY">International Economy</option> </select> </p> <p id='prioMsg' style='display:none;color:#006777;'>Hazardous samples must be shipped using priority services.</p> <p>The customer incurs shipping costs. All shipments are delivered by FedEx.</p> <p>Please note: we do not provide receipts for sample requests.</p> <p>Arrangements for sample pickup can also be made; we will provide the sample and packaging only.</p> <p>Samples to universities are available in the US and Canada only.</p> <p>Thank you!</p> </div> <div style="overflow:auto;"> <div style="float:right;"> <button type="button" id="prevBtn" onclick="nextPrev(-1)">Previous</button> <button type="button" id="nextBtn" onclick="nextPrev(1)">Next</button> </div> </div>  <div style="text-align:center;margin-top:40px;"> <span class="step"></span> <span class="step"></span> <span class="step"></span> <span class="step"></span> <span class="step"></span> </div>   </form> <script language="javascript"> print_state('state','USA'); var currentTab = 0; // Current tab is set to be the first tab (0) showTab(currentTab); // Display the current tab function showTab(n) { // This function will display the specified tab of the form ... var x = document.getElementsByClassName("tab"); x[n].style.display = "block"; // ... and fix the Previous/Next buttons: if (n == 0) { document.getElementById("prevBtn").style.display = "none"; } else { document.getElementById("prevBtn").style.display = "inline"; } if (n == (x.length - 1)) { document.getElementById("nextBtn").innerHTML = "Submit"; } else { document.getElementById("nextBtn").innerHTML = "Next"; } // ... and run a function that displays the correct step indicator: fixStepIndicator(n) } function nextPrev(n) { // This function will figure out which tab to display var x = document.getElementsByClassName("tab"); // Exit the function if any field in the current tab is invalid: if (n == 1 && !validateForm()) return false; // Hide the current tab: x[currentTab].style.display = "none"; // Increase or decrease the current tab by 1: currentTab = currentTab + n; // if you have reached the end of the form... : if (currentTab >= x.length) { //...the form gets submitted: document.getElementById("sampleForm").submit(); return false; } // Otherwise, display the correct tab: showTab(currentTab); } function validateForm() { // This function deals with validation of the form fields var x, y, i, valid = true; x = document.getElementsByClassName("tab"); //y = x[currentTab].getElementsByTagName("input"); y = x[currentTab].getElementsByClassName("req"); // A loop that checks every input field in the current tab: for (i = 0; i < y.length; i++) { // If a field is empty... if (y[i].value == "" && y[i].className =="req") { // add an "invalid" class to the field: y[i].className += " invalid"; // and set the current valid status to false: valid = false; } } // If it's the last tab, set the shipping method if(x[currentTab].id=="lastTab"){ if(document.getElementById("requestType").value!="General Enquiry"){ if(document.getElementById("CCNumber").value==""){ document.getElementById("CCNumber").className+=" invalid"; valid = false; } } hazTotal=0; nonHazTotal=0; jQuery("input[id='00N300000013jAL[]']:checked").each(function (){ if(jQuery(this).attr('class')=='haz'){ hazTotal=hazTotal+1; } else{ nonHazTotal=nonHazTotal+1; } }); if(hazTotal>0){ if(document.getElementById("shipMethod").value!="PRIORITY_OVERNIGHT"){ document.getElementById("prioMsg").style.display="block"; jQuery('#shipMethod').val('PRIORITY_OVERNIGHT').prop({selected: true}); document.getElementById("shipMethod").className+=" fadeout"; valid = false; } } } // BEGIN Nissan specific if(fullName.value.length>0){valid = false;} if(first_name.value.substr(0,10)==company.value.substr(0,10)){valid = false;} // END Nissan specific // If the valid status is true, mark the step as finished and valid: if (valid) { document.getElementsByClassName("step")[currentTab].className += " finish"; } return valid; // return the valid status } function countSamples(){ var count, samples, state; count = document.querySelectorAll('input[id="00N300000013jAL[]"]:checked').length; samples = document.getElementsByName('00N300000013jAL[]'); if(count >= 3){ state = true; }else{ state = false; } // Toggle the chkboxes. >=3, disable them. Otherwise, enable them. for(var i = 0; i < samples.length; ++i) { if(samples[i].checked == false){ samples[i].disabled = state; } } } function fixStepIndicator(n) { // This function removes the "active" class of all steps... var i, x = document.getElementsByClassName("step"); for (i = 0; i < x.length; i++) { x[i].className = x[i].className.replace(" active", ""); } //... and adds the "active" class to the current step: x[n].className += " active"; } </script> </div> <footer class="entry-meta"> </footer> </article> </div> </div> </div></div></div> <footer id="colophon" class="site-footer" role="contentinfo"><div class="container"> <div class="colophon-inner colophon-grid-1"> <div class="colophon-column-left"> <div class="colophon-column"> <div class="copyright"> © 2007-2025 Nissan Chemical America Corporation </div> </div> </div>  <div class="colophon-column-right"> <a href="/privacy/">Privacy</a> </div>  </div> </div></footer> </div><a href="#page" class="scrollup" id="btn-scrollup"><i class="fa fa-long-arrow-alt-up" aria-hidden="true"></i></a> <script type="text/javascript" src="https://nissanchem-usa.com/wp-includes/js/dist/hooks.min.js?ver=4d63a3d491d11ffd8ac6" id="wp-hooks-js"></script> <script type="text/javascript" src="https://nissanchem-usa.com/wp-includes/js/dist/i18n.min.js?ver=5e580eb46a90c2b997e6" id="wp-i18n-js"></script> <script type="text/javascript" id="wp-i18n-js-after"> /* <![CDATA[ */ wp.i18n.setLocaleData( { 'text direction\u0004ltr': [ 'ltr' ] } ); /* ]]> */ </script> <script type="text/javascript" src="https://nissanchem-usa.com/wp-content/plugins/contact-form-7/includes/swv/js/index.js?ver=6.0.2" id="swv-js"></script> <script type="text/javascript" id="contact-form-7-js-before"> /* <![CDATA[ */ var wpcf7 = { "api": { "root": "https:\/\/nissanchem-usa.com\/wp-json\/", "namespace": "contact-form-7\/v1" } }; /* ]]> */ </script> <script type="text/javascript" src="https://nissanchem-usa.com/wp-content/plugins/contact-form-7/includes/js/index.js?ver=6.0.2" id="contact-form-7-js"></script> <script type="text/javascript" src="https://nissanchem-usa.com/wp-content/themes/biosocket-one/js/skip-link-focus-fix.min.js?ver=20130115" id="biosocket-one-skip-link-focus-fix-js"></script> <script type="text/javascript" src="https://nissanchem-usa.com/wp-content/themes/biosocket-one/third-party/cycle2/js/jquery.cycle2.min.js?ver=2.1.6" id="jquery-cycle2-js"></script> <script type="text/javascript" src="https://nissanchem-usa.com/wp-content/themes/biosocket-one/third-party/sidr/js/jquery.sidr.min.js?ver=2.2.1" id="jquery-sidr-js"></script> <script type="text/javascript" src="https://nissanchem-usa.com/wp-content/themes/biosocket-one/js/custom.min.js?ver=1.0.0" id="biosocket-one-custom-js"></script> <script> document.querySelectorAll('h1').forEach((h1) => { h1.innerHTML = h1.innerHTML.replace(/®/g, '<sup>®</sup>'); }); </script> </body> </html>