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					                                                                                                                                Claim form
Epson cash back offer on selected laser printers

                               Title                                               First name
             Company name
                           County                                                                      Postcode
Daytime telephone number
                Email address
            Date of purchase
       Printer serial number

                                                                                           Cash back
                                                                                                        Indicate the product
                                        Model                                               amount                             Quantity
                                                                                                        you are claiming for
                                                                                            (ex VAT)
                                        AcuLaser M2000D / DT                                    £50
                                        AcuLaser M2000DN / DTN                                  £75
                                        EPL- N2550 series                                       £100
                                        EPL- N3000 series                                       £100
                                        AcuLaser C4200DN series                                 £100
                                        AcuLaser M4000 series                                   £150
                                        AcuLaser C9200 series                                   £200

We may use the information you have provided to send you details about similar Epson products, services or offers.
         If you WOULD LIKE to receive information by email please tick this box.

         If you WOULD LIKE to receive information by post please tick this box.

We may, from time to time, wish to contact you for market research purposes.
         If you WOULD LIKE to be contacted about market research please tick this box.

Claim checklist. Please supply:-
1 Completed claim form (this sheet)
2 Original proof of purchase (not proof of order). Your original proof of purchase will be returned to you with your
  cash back cheque.
3 Please indicate below by ticking the relevant box if you are a VAT registered company.

          Please tick here if you are a VAT registered company
          VAT number

The self-billee with the above stipulated VAT registration number agrees:
1) To accept invoices raised by the self-biller on their behalf for this offer
2) Not to raise rebate invoices for the transaction covered by this offer
3) To notify the self-biller immediately if they
   i) change their VAT registration number ii) cease to be VAT registered iii) sell their business or part of their business.
If you agree to the above terms and conditions please sign and date below. We regret if you have failed to
sign and date this declaration we are unable to process your claim.

Signature                                                                          Date

Please send to:
‘Laser Printer Cash Back Offer’, Epson (UK) Ltd. Campus 100,
Maylands Avenue, Hemel Hempstead, Hertfordshire. HP2 7TJ, United Kingdom.

Please note Epson must receive your claim within 30 days from the date of purchase.
Company details on the claim form must be the same as on the proof of purchase.

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