Device Contact

APPENDIX

Business Entities participating in this Offer must also complete the form below and upload it as a .PDF in addition to the Qualifying Purchase receipt file, as described in Section 3B of these Terms and Conditions. Samsung TV Flash Sale

B2B/CL Offer Claim Form

1. Complete this B2B/CL Offer Claim Form

2. Upload on redemption site:

Copy of the transaction receipt(s) with Qualifying Samsung Device purchase(s)

This B2B/CL Offer Claim Form completed with each Qualifying Samsung Device WIFI MAC address and IMEI or HEX MEID in .PDF format

Must meet all eligibility requirements as set forth in the Terms and Conditions to receive the Offer Item. Offer Claim Forms must be submitted by December 31, 2015. Allow approx. 4-6 weeks from verification of Offer Claim Form for shipping of Offer Items.

By signing below, I agree that I have read and agree to the Terms and Conditions above and available at http://promo.samsungpromotions.com/SamsungTVFlashSale Name (no initials): Signature: Email Address: Mobile Number: Company Name: B2B Rep/Dealer/Agent: Date of Qualifying Samsung Device Purchases: Ship to Company Name: Ship to Contact Name: Ship to Contact Mobile Number: Shipping Address: (No PO Boxes) City: State: Zip: Ship to Contact Email Address: Samsung TV Flash Sale

B2B/CL Offer Claim Form

Please complete below for each Qualifying Samsung device purchase First Name Last Name Samsung

Device

Purchased

(GS6, GS6

edge, GS6

edge+ or

Note5)

Samsung

Device WIFI

MAC address

Samsung Device

IMEI or HEX

MEID

Samsung

Device

Telephone

Number

Contact this candidate