Tablet_Reciept_ENG

TABLET AGREEMENT AND RECEIPT FORM

[TO BE ENCLOSED WITH TABLET SHIPMENT, OR COLLECTED BY FIELD INTERVIEWER]

Ask U.S. Panel pilot Tablet Agreement and Receipt Form
The US Census Bureau and RTI International would like to thank you for participating in the Ask U.S. Panel pilot. To help you access the internet and participate in the pilot panel, we are providing you with a Samsung Galaxy Tab A7 tablet with an unlimited data plan to complete the pilot panel web surveys and receive any other correspondences while you participate in the pilot panel. By signing below, you acknowledge that: RTI International provided you with a new Samsung Galaxy Tab A7, so you may complete surveys as a pilot panel member for the Ask U.S. Panel pilot, For your participation in the Ask U.S. Panel pilot, you are provided with unlimited data plan, paid for by RTI International, At the conclusion of the pilot panel, the data plan will be discontinued [IF SHIPPED, FILL: Please return this form using the enclosed postage paid envelope within 7 business days of receiving the tablet.]
Please check each box below to confirm receipt of items: Received Samsung Galaxy Tablet Received Samsung Galaxy Tablet Charger Received Samsung Galaxy Tablet Case
Name:	Signature:	Date:
If you have any questions about your tablet you can contact the Ask U.S. Panel pilot support team at 1-866-558-0774 or askuspanel@rti.org. OMB Number: ####-####; Expiration Date: ##/##/####

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