Along with the name and mailing address, leave an email address please and a list of any allergies/sensitivities you have like mineral oil, cocoa butter, etc. Likely won't be suitable for Vegans as I do use beeswax in most things of this nature.
There will also be a survey/poll posted a few days after the samples are sent out with questions about texture, flavor, etc. and if you ask for samples you'd be expected to fill that out when you've had a chance to try things. I figure most of you knew that already!