Request A Device

Device Request Form

Fee structure varies between $150-$800 depending on the device available

Account name: DijiRed Ltd
BSB: 806015
Account: 02024198

Please note to request a device you must reside in Western Australia

Subject

Agency details:

Agency Name (*if you are an agent requesting on behalf of a client)

Agent Name

Phone Number

Email Address

Information of the Person Requesting

Name

Date of Birth

Email Address

Phone Number

Address

Name of Internet Provider(ISP)

If applicable

Name of Course

Name of School

Year

If Yes. Type of concession

Reason for needing a device / Additional information (*Required)

Please attach proof of concession or enrollment here

Please note that the fee is payable once approved.

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