$200 CASHBACK ON HD EVERIO*

Your details [*Required fields]
*First Name
*Last Name
*Date of Birth	/ / DD/MM/YYYY
Residential Address
*Address 1
Address 2
*Suburb		*State	*Postcode
(Cashback cheque will be sent to Residential Address unless an alternative Postal Address is provided)
Postal Address
	Same as above
Address 1
Address 2
Suburb		State	Postcode
contact details
*Daytime Phone
Business Phone
Mobile
*Email
*Email (Completed claim form will be sent to this email address to be printed)
DETAILS OF YOUR PURCHASE
*Date of eligible purchase (as on sales receipt, must be between 29/09/2008 and 31/12/2008 inclusive)
*Date of eligible purchase
*Purchase Store
*Purchase Suburb
*Purchase State
*Serial Number
(Your camcorder Serial Number can be found on the sticker, which is on the box containing the barcode. The Serial Number is in the set of numbers on the right hand side under the second barcode strip)
*Product Purchased
	GZ-HD5AA
	GZ-HD6AA
	GZ-HD10AA
	GZ-HD30AA
	GZ-HD40AA
*I have read and agree to the Terms and Conditions relating to this promotion.

Your details [*Required fields]