*Please fill up the form below to request for your sample of Berocca Performance: MAHS0600208 Title Mr. Mrs. Ms. Name* Promotional Code Email* Address* Postcode* Contact number Privacy Statement In handling the personal data you provide, we will comply with the applicable data protection legislation and will keep it confidential, in accordance with our Privacy Statement. You hereby consent to the storage, processing, and use of your personal data provided to us which may also be transferred to companies within the Bayer Group for the purpose of providing you with the requested sample of products; or for sharing product-related information and updates on promotional activities. By accepting the Privacy Statement, you further agree that you are aged eighteen (18) years old and above. Privacy Statement accepted* Terms and Conditions Subject to availability, sample pack is open to residents in Singapore aged eighteen (18) years old and above only. Please fill in the compulsory information indicated by asterix (*) to facilitate the delivery of sample pack. Only one sample pack will be allocated per applicant / per postal address regardless of the number of applications submitted. Bayer reserves the right to change the terms and conditions at its discretion without any advance notice.