Microsoft Surface Pro Tablet Request Form

Please fill out the form below to request the Microsoft Surface Pro Tablet PC promotion for your purchase of three (3) or more Hitachi cameras with IP-capable CCUs. We will confirm receipt of your request via Email. Contact us via Email at engineering@hitachikokusai.us or call our toll free number (855) 891-5179 during normal business hours.

The fields indicated with an asterisk (*) are required.

Contact Information

Company *
Name * First name *
Middle Initial
Last name *
Address *
City *
State/Province *
Zip/Postal Code *
Country *
Email *
Company Phone *
Cell Phone *

Camera Products Purchased (Minimum of 3 cameras required)

Camera #1 * Model *
Serial No. *
Camera #2 * Model *
Serial No. *
Camera #3 * Model *
Serial No. *
Dealer or Reseller *
Date of Purchase *