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

Please select:

AgencyPersonal

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

Male or Female
MaleFemale

Email Address

Phone Number

Address

Do you/they have an Internet connection at home?
YesNo

Name of Internet Provider(ISP)

Are you/they enrolled to study?
YesNo

Is this course online?
YesNo

If applicable

Name of Course

Name of School

Year

Any concession eligibility
YesNo

If Yes. Type of concession

Are you/they of Aboriginal or Torres Strait Islander origin?
AboriginalTorres Strait IslanderOther

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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