1.  PLEASE CHOOSE THE DELIVERY DATE THAT COINCIDES WITH YOUR ARRIVAL ON CAMPUS:

INTERNET ORDERING CLOSED Check delivery information and maps of college locations (link will open in a new window)

2.  SCHOOL:

INTERNET ORDERING CLOSED ALBANY STATE

3.  COUNTY:

ALBANY

4.  SCHOOL CITY:

ALBANY

5.  SCHOOL STATE:

NEW YORK

6.  SCHOOL ZIP:

12222 12203    12222 - University at Albany Zip Code.  12203 - Alumni Quad Zip Code.

7.  ORDER METHOD:

INTERNET PHONE (office use only) MAIL (office use only) OTHER

8.  TYPE:

ORDER

9.  TODAY'S DATE: PLEASE ENSURE YOU HAVE PRESSED THE CAPS LOCK KEY BEFORE CONTINUING

mm-dd-yy (you must use dashes for date to be entered properly)

If you do not have the information for questions 10 -14,don't worry. You can email it to us as soon as you have it!   Email address: refrigeratorleasingcompany@yahoo.com

10.  QUADRANGLE:

PLEASE SELECT BELOW QUAD NOT ASSIGNED ALUMNI COLONIAL DUTCH FREEDOM INDIAN STATE OTHER

11.  HALL:

PLEASE SELECT BELOW HALL NOT ASSIGNED ADIRONDACK ALDEN ANTHONY BLEEKER BEVERWYCK CAYUGA CLINTON CLUSTER A CLUSTER B CLUSTER C CLUSTER D COOPER DELANCEY EASTMAN TOW EMPIRE COMMONS FULTON HAMILTON HERKIMER IRVING JOHNSON LIVINGSTON TOW MADISON AVE MAHICAN MELVILLE MOHAWK TOW MONTAUK MORRIS ONEIDA ONONDAGA PAINE PIERCE RYCKMAN SAYLES SCHUYLER SENECA STANTON STEINMETZ STUYVESANT TOW TAPPAN TEN BROECK TEN EYCK TRUTH TUSCARORA VANCORTLAND VANRENSSELAER WATERBURY WHITMAN ZENGER If your hall is not listed, please add it to the notes line at the end of this form

12.  ROOM:

13. STUDENT CELL PHONE:

14.  STUDENT EMAIL ADDRESS:

15.  STUDENT'S FIRST NAME:

16.  STUDENT'S LAST NAME:

17.  YOUR FIRST NAME:

18.  RELATIONSHIP TO STUDENT:

PARENT SELF OTHER OFFICE

19.  HOME ADDRESS:

20.  HOME CITY:

21.  HOME STATE:

22.  HOME ZIP:

23.  PARENT CELL PHONE:

24.  PARENT EMAIL ADDRESS:

25.  CLASS:

FRESHMAN SOPHOMORE JUNIOR SENIOR GRAD STUDENT OTHER

26.  FRIDGE TYPE:

PLEASE SELECT BELOW NEW MICROFRIDGE USED MICROFRIDGE NEW MF AND SAFE USED MF AND SAFE BUY SAFE COUNTER HIGH CUBE

27.  FRIDGE PRICE:

                        PLEASE SELECT BELOW 469.00 267.50 658.99 457.49 189.99 110.00 70.00   PLEASE SELECT THE PROPER PRICE:

28.  TOTAL PRICE:  In this blank (item 28), insert the same price you selected above for item 27.

               Entering the total price into the box means you authorize this amount to be charged on your credit card.

29.  CREDIT CARD NUMBER WITH SPACES: 

            Visa/Mastercard only

Example: 3333 3333 3333 3333 (You must use spaces between the numbers for credit card to be read properly.  If you do not use spaces, the order will not submit and you will be asked to properly enter the credit card.)

30.  EXPIRATION DATE :

Example: 0413   Please use the proper number for the month, not abbreviations. Please do not separate the month and year with any punctuation or spaces.

31.V-CODE:   (The V-Code is the last 3 digits found on the back of the credit card following the account number)

32.  ARRIVAL DATE:

mm-dd-yy (you must use dashes for date to be entered properly)

33.  NON-FRESHMAN:  Did you rent a MicroFridge from us last year?

PLEASE SELECT BELOW YES NO

Please print the Form Confirmation page that appears after you submit the form.  It will be your only copy of this form. If you need to contact us for any reason, please email us at refrigeratorleasingcompany@yahoo.com