Fiara Pty Ltd PO Box 12223 A’Beckett Street Melbourne VIC 8006 Australia T. 1300 19 79 29 info@fiara.com.au www.fiara.com.au ABN 53 161 689 854 Anti-Blue Light Screen Filter: Free Sample Request Form Applicant Information School / Company Name: ABN: Title:　Mr.　/　Mrs.　/　Ms.　/　Miss First Name: Last Name: Position: Tel: Mobile: Fax: Company Website: Company Email Address: Office Address: Suburb: State: Postcode: How many filters will you order if the sample passes evaluation? How did you find us? Would you like to receive our product update via email? Yes / No PL-BLU Series Sample Information (Fiara Pty Ltd only accept MAXIMUM 3 samples per application and free samples are only for SELECTED Models. (Please refer to below Terms and Conditions) Series Code ☐ PL-BLU19 ☐ PL-BLU20 ☐ PL-BLU22 ☐ PL-BLU24 Quantity Fit to Screen Size Width (mm) Height (mm) Depth (mm) RRP (AUD) 19"(inch) 440 290 45 20"(inch) 475 315 45 22"(inch) 510 330 45 24"(inch) 550 340 45 $119.00 + GST $129.00 + GST $135.00 + GST $145.00 + GST Measure Instruction: 1. We recommend that you measure the screen/monitor diagonally. 2. Measure the screen/monitor (without the frame) not the equipment and refer to the above product description. Terms and Conditions 1. This application form is only to be used by Australian schools or companies to request a free sample(s) for evaluation. Other organisations who have interest in evaluating our sample(s) please send us email, mail or call us to request. 2. The purpose of the free sample program is to provide schools or companies a "free trial before you buy" purchase experience. Since the resource is limited, if your school or company has no intention to purchase even if the sample(s) passes the evaluation, please kindly leave this opportunity to other schools or companies. 3.You can choose any one of the following samples:PL-BLU19; PL-BLU20; PL-BLU22 or PL-BLU24. If the product that you want to buy is not in the free sample program, you are welcome to send us an email to info@fiara.com.au or mail to us on PO Box 12223 A'Beckett street Melbourne VIC 8006. We will consider the situation and see what we can do to assist you to evaluate the product. 4. Fiara Pty Ltd will send out the sample(s) to the approved applicant as soon as possible according to its stock level and location etc. 5. Free sample program do not include postage and handling, charge will be calculated based on your location, quantity and the size of the sample(s). 6. Amount of postage and handling charge will be advised by email. Method of payment can be made via credit card, PayPal or bank transfer. 7. Postage and handling charge in free sample program will be fully refunded when genuine purchase is made. 8. Free sample(s) is only for trailing purpose. Fiara Pty Ltd has no responsibilities to the applicant, and as such is not liable from any losses or damages, either physical or financial occurring due to any cause, including negligence. 9. Fiara Pty Ltd reserves the right to terminate the Free Sample Program at its own discretion. Applicant Signature: Date: Please email the completed form to info@fiara.com.au for sample(s) requisition, Thank You!!! Fiara - Pleasant, Simple, Peace of mind!