1.  FIRST DELIVERY DATE:

WEDNESDAY, AUGUST 31 Check delivery information and maps of college locations (link will open in a new window)

2.  SCHOOL:

ITHACA

3.  COUNTY:

TOMPKINS

4.  SCHOOL CITY:

ITHACA COLLEGE

5. SCHOOL STATE:

NEW YORK

6. SCHOOL ZIP:

14850

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 12-15, don't worry.  You can email it to us as soon as you have it!   Email address: rent62@dmcom.net

11.  HALL:

PLEASE SELECT BELOW HALL NOT ASSIGNED BOGART BOOTHROYD CLARKE EAST TOWER EASTMAN EGBERT EMERSON GARDEN APARTMENTS HILLIARD HOLMES HOOD LANDON LYON ROWLAND TALCOTT TERRACE 01 TERRACE 02 TERRACE 03 TERRACE 04 TERRACE 05 TERRACE 06 TERRACE 07 TERRACE 08 TERRACE 09 TERRACE 10 TERRACE 11 TERRACE 12 TERRACE 13 WEST TOWER If your hall is not listed, please email us at refrigeratorleasingcompany@yahoo.com

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.  PRODUCT TYPE: Select the product or products 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

                    $319.99     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: 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: 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