1.  FIRST DELIVERY DATE:

MONDAY, AUGUST 29 Check delivery information and maps of college locations (link will open in a new window)

2.  SCHOOL:

SUNY PURCHASE

3.  COUNTY:

WESTCHESTER

4.  SCHOOL CITY:

PURCHASE

5.  SCHOOL STATE:

NEW YORK

6.  SCHOOL ZIP:

10577

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:

HALL NOT ASSIGNED ALUMNI VILLAGE BIG HAUS CAMPUS CENTER COMMONS CROSSROADS FARSIDE FORT AWESOME NEW OUTBACK THE OLDE OTHER PLEASE SELECT BELOW

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 MICROFRIDGE

27.  FRIDGE 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 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: 8888 8888 8888 8888 (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)31.  STUDENT

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