This form is to be completed in full by the assessor or the trial will not be processed. Fields marked with an asterisk are mandatory.

Assessor Name: *
Organisation/ Company: *
Telephone: *
Fax: *
Assessor's Email: *
Postal Address:
Delivery Address: *
Client's Name:
Client's Phone:
Date required for trial:
Client's Address:
Items required for trial:	KM7520 KM8000 KP25 Other
Tick here if quote is also required:
If this trial is successful, it will be funded by: *	Accessable - MOH Enable New Zealand Other
Tick here if approval for trial has been given: *
Trial Approval Number: *