Your Information 
 
 
Brewery Name*
 
 
Street Address*
 
 
 
City*
 
 
State / Province*
 
 
 
Number of barrels you pledge to produce*
 
 
 
 
 
 
 
Requester's First Name*
 
 
Requester's Last Name*
 
 
 
Requester's Email*
 
 
Requester's Phone Number*
 
 
 
 
 
Products 
 
 
Please select the product(s) that you need to participate in the event. 
 
 
 
 
1. Pilsner Malt (Choose one) 
 
 
Great Western Malting Superior Pilsen Malt 
GW-PILS Quantity*
 
 
 
OR Canada Malting Co. Superior Pilsen Malt 
CM-SPIL Quantity*
 
 
 
 
 
 
2. Wheat Malt (Choose one) 
 
Great Western Malting White Wheat Malt 
GW-WWHT Quantity*
 
 
 
OR Canada Malting Co. White Wheat Malt 
CM-WWHT Quantity*
 
 
 
OR Canada Malting Co. Red Wheat Malt 
CM-RWHT Quantity*
 
 
 
 
 
 
3. Great Western Malting Dextra Pils® Malt 
 
 
GW-DEXT Quantity*
 
 
 

4. Canada Malting Co. Flaked Oats  
 
 
CM-FBOT Quantity*
 
 
 
 
 
 
5. AB Biotek Pinnacle English Ale 
 
 
AB-PHEA (by 500g brick)*
 
 
 
 
 
 
 
 
Additional Information 
 
 
 
 
 
Does the malt you selected need to be milled?*
 
 
If YES, which specs do you need your malt milled to?
 
 
 
How would you like to receive your product? *
 
 
 
Would you like your sales rep to contact you about adding additional (non-donated) products to your order to maximize your pallet?*