| First Name, MI* | |
| Last Name* | |
| Dorm and room # (delivery address) | |
| Your home (not the school) Address* | |
| Your home city and state* | |
| Arrival Date* | |
| Zip/Postal Code (home) * | |
| Contact Phone* | |
| EMAIL Address (SEE BELOW)** |
**THE E MAIL ADDRESS THAT YOU PROVIDE ABOVE WILL BE USED FOR ALL CORRESPONDENCE WITH YOU THROUGHOUT THE SCHOOL YEAR. IF YOU CHANGE YOUR MAIN E MAIL ADDRESS, PLEASE CONTACT US SO THAT YOU WILL NOT MISS INFORMATION REGARDING THE COLLECTION AT YEAREND.
2) PLEASE CHECK THE ITEMS YOU WISH TO RENT
(ALL PRICES ARE PER ACADEMIC SCHOOL YEAR )
| DESCRIPTION | ||
| MICR0WAVE-FRIDGE................$185.34 + $10.66TAX=$196.00 | ||
| 3.0 CU.FT. FRIDGE/FREEZER........$139.01+$7.99 TAX=$147.00 | ||
| 20" COLOR TELEVISION..............$93.62 + $5.38 TAX= $99.00 | ||
| * | REFUNDABLE DEPOSIT (REQUIRED)........................$10. |
ORDER TOTAL :
PLEASE TELL US HOW YOU HEARD ABOUT OUR COMPANY
A POSTER/FLYER LOCATED IN MY DORM
INFORMATION MAILED TO ME
INFORMATION DISTRIBUTED BY SCHOOL OFFICIALS AT ORIENTATION
OTHER STUDENTS
I AM A PREVIOUS CUSTOMER
3) PLEASE SELECT YOUR METHOD OF PAYMENT
PLEASE CHARGE THIS TO MY CREDIT CARD. . PRESS THE SUBMIT BUTTON TO ORDER ELECTRONICALLY OR PRINT AND MAIL THIS FORM TO CAMPUS RENTALS, 502 E FRANKLIN AVE., SILVER SPRING, MD 20901.
ONCE WE PROCESS YOUR ORDER, WE WILL SEND A CONFIRMATION (USUALLY WITHIN 24 HOURS) TO THE EMAIL ADDRESS YOU HAVE GIVEN WITH YOUR SPECIFIC DELIVERY INFORMATION.
VISA OR MASTERCARD
| CREDIT CARD NUMBER | |
| EXPIRATION DATE |
 |
Questions or comments about your order? Please contact us at: www.campusrentalsau@aol.com
4) I HAVE READ AND AGREE TO THE TERMS OF THE RENTAL AGREEMENT STATED HEREIN. (CHECK BOX)