First Name, MI*
Last Name*
Dorm & Room #*
Home Address*
City & State*
Zip/Postal Code*
Contact Phone*
EMAIL Address*

		DESCRIPTION*
		SCHEDULE A MID SEMESTER PICKUP.............................$35
		RESCHEDULE ATTEMPT FOR A  MISSED  PICKUP .................................................................................................$35**
		TRANSFER A CONTRACT..................................................$35
		RESCHEDULE A MISSED SERVICE CALL.........................$35
		SCHEDULE A PICKUP ATTEMPT FOR EQUIPMENT THAT HAS BEEN LEFT IN THE DORM AFTER CHECKOUT................$50 **
		APPOINTMENT TIMES AVAILABLE:
		we will advise

   * SERVICE FEES ARE PER ATTEMPT.  IF WE YOU MISS A SCHEDULED SERVICE CALL OR PICKUP,  YOU WILL NEED TO PAY AN ADDITIONAL SERVICE FEE AND RESCHEDULE AN ADDITIONAL ATTEMPT.  YOU MUST BE PRESENT WHEN WE ARRIVE.

** REQUESTING A PICKUP DOES NOT RELIEVE YOU FROM YOUR CONTRACTUAL OBLIGATION TO RETURN RENTAL EQUIPMENT TO US.  IF YOU ARE NOT PRESENT WHEN WE ARRIVE AND WE ARE UNABLE TO LOCATE OR GAIN ACCESS TO THE EQUIPMENT, YOU WILL STILL BE LIABLE FOR IT'S FULL REPLACEMENT VALUE AS OUTLINED IN YOUR CONTRACT.

 ORDER  TOTAL :  

    PLEASE CHARGE THIS TO MY CREDIT CARD. .     PRESS THE SUBMIT BUTTON TO ORDER ELECTRONICALLY .

*ONCE WE PROCESS YOUR ORDER, WE WILL SEND A DETAILED CONFIRMATION  TO THE  EMAIL ADDRESS ABOVE. IF THE SERVICE YOU ARE REQUESTING IS NOT AVAILABLE, YOU WILL NOT BE CHARGED. YOU MUST BE AT YOUR ROOM WHEN WE ARRIVE OR WE WILL HAVE TO MOVE ON AND THE APPOINTMENT WILL BE CONSIDERED  MISSED.

VISA OR MASTERCARD

CREDIT CARD  NUMBER
EXPIRATION DATE

        BY SUBMITTING THIS ORDER YOU AGREE TO ABIDE BY THE TERMS OF THE RENTAL AGREEMENT STATED HEREIN.