1.  FIRST DELIVERY DATE:

TUESDAY, AUGUST 17    Pre Arrival Delivery

2.  SCHOOL:

ALFRED STATE

3.  COUNTY:

ALLEGANY

4.  SCHOOL CITY:

ALFRED

5.  SCHOOL STATE:

NEW YORK

6.  SCHOOL ZIP:

14802

7.  ORDER METHOD:

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

8.  TYPE:

ORDER

9.  TODAY'S DATE:  PLEASE ENSURE YOUR CAPS LOCK KEY IS ON (WE NEED CAPITAL LETTERS IN FORM)

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

10.  ON CAMPUS RENTAL:

YES..........

If you do not have the information for questions 11-14, don't worry.  You can email it to us as soon as you have it.  Our Email Address is: refrigeratorleasingcompany@yahoo.com

11.  HALL:

PLEASE SELECT BELOW HALL NOT ASSIGNED BRADDON BURDICK GETMAN MACKENZIE NORTH MACKENZIE SOUTH MACKENZIE EAST MACKENZIE WEST MAIN GATE A MAIN GATE B PEET SHULTS OTHER ROBINSON CHAMPLIN GETMAN If your hall is not listed, please add it to the Notes Line at the end of the form.

12.  ROOM:

13.  SCHOOL PHONE OR STUDENT CELL PHONE::

14.  COLLEGE 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.  HOME PHONE:

24.  PRIMARY EMAIL ADDRESS:

25.  CLASS:

FRESHMAN SOPHOMORE JUNIOR SENIOR GRAD STUDENT OTHER

26.  PRODUCT TYPE: Select the product or products you would like to rent in the box below:

SAFE COUNTER HIGH CUBE

27.  FRIDGE PRICE: PLEASE SELECT THE PROPER PRODUCT PRICE FROM THE DROP DOWN MENU BELOW:

99.99 120.00 60.00   PLEASE SELECT PROPER PRICE: 

                $99.99 SAFE

                $120.00  COUNTER HIGH         

                $60.00 CUBE MODEL

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

               Entering the total price into the box means you have read and understood the Terms and Conditions

                                    and you authorize this amount to be charged on your credit card.

29.  CREDIT CARD NUMBER WITH SPACES: 

            Visa/Mastercard only

Example: 0000 0000 0000 0000 (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. 0404 Please use the proper two digit number for the month, no 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.  STUDENT ARRIVAL DATE:

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

33. ARE YOU AN RA (RESIDENT ASSISTANT)?:

  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