By submitting this form, you are agreeing to these Terms and Conditions

DO NOT PRESS ENTER UNTIL YOU HAVE COMPLETED ALL FIELDS AND ARE READY TO SUBMIT THE FORM. 

If you press enter by mistake, use the "back" button, and continue from last completed field.

1.  FIRST DELIVERY DATE:

FRIDAY, SEPTEMBER 2 Check delivery information and maps of college locations (link will open in a new window)

2. SCHOOL:

BUFFALO STATE

3.  COUNTY:

ERIE

4.  SCHOOL CITY:

BUFFALO

5.  SCHOOL CITY:

NEW YORK

6.  SCHOOL ZIP:

14222

7.  ORDER METHOD:

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

8.  TYPE:

ORDER

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

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!   Email address: refrigeratorleasingcompany@yahoo.com

11.   HALL:

PLEASE SELECT BELOW HALL NOT ASSIGNED ADAMS MARK HOTEL CASSETY MOORE COMPLEX NEUMANN NORTHWING PERRY PORTER TOWER 01 TOWER 02 TOWER 03 TOWER 04 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 the product you would like to rent in the box below

PLEASE SELECT BELOW MICROFRIDGE RENT SAFE MICROFRIDGE AND SAFE COUNTER HIGH CUBE

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

  319.99 220.00 99.99 120.00 60.00    Put your price selection from the products below into the box

                     $299.99     RENT A MICROFRIDGE AND SAFE

                     $220.00     RENT A MICROFRIDGE

                     $99.99       RENT A SAFE

                     $120.00       RENT A COUNTER HIGH MODEL REFRIGERATOR

                     $60.00       RENT A CUBE MODEL REFRIGERATOR

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 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: 5555 5555 5555 5555 (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. STUDENT 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