Hamilton Order Form

TO ORDER A UNIT FOR HAMILTON,

 PLEASE CALL OUR OFFICE AT

607-431-9525

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE DO NOT USE THE FORM BELOW

 

PLEASE PRESS CAPS LOCK KEY NOW.

Please begin at Question 9.  Use your mouse or the TAB key to navigate through the form. 

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:

More delivery dates will be posted after this date.

2.  SCHOOL:


3.  COUNTY:


4.  SCHOOL CITY:


5.  SCHOOL STATE:


6.  SCHOOL ZIP:


7.  ORDER METHOD:


8.  TYPE:


9.  TODAY'S DATE:

mm-dd-yy (You must use dashes for date to be entered properly)

10.  ON CAMPUS RENTAL:


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!  Our Email Address: rent62@dmcom.net

11.  HALL:

If your hall is not listed, please add it to the Notes Line at the end of the form.

12.  ROOM:


13.  SCHOOL PHONE OR STUDENT CELL PHONE:

Or choose which to use when contacting student

14.  COLLEGE EMAIL ADDRESS:


15.  STUDENT'S FIRST NAME:


16.  STUDENT'S LAST NAME:


17.  YOUR FIRST NAME:


18.  RELATIONSHIP TO STUDENT:


19.  HOME ADDRESS:


20.  HOME CITY:

 

21.  HOME STATE


22.  HOME ZIP:

23.  HOME PHONE:

24.  PRIMARY EMAIL ADDRESS:


25.  CLASS:


26.  FRIDGE TYPE:


27.  FRIDGE PRICE:

$200.00 MICROFRIDGE

$85.00 COUNTER HIGH

$60.00 CUBE MODEL

PLEASE SELECT THE PROPER PRICE: 

28.  TOTAL PRICE:

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:  Visa/Mastercard

Example: 0000 0000 0000 0000 (You must use spaces between the numbers for credit card to be read properly.)

30.  EXPIRATION DATE:

Example: 0409 Please use the proper number for the month, not abbreviations. Please do not separate the month and year with any punctuation or spaces.

31.  STUDENT ARRIVAL DATE:

mm-dd-yy (You must use dashes for date to be entered properly)

32.    ARE YOU AN RA (RESIDENT ASSISTANT)?

 

33.  NON-FRESHMAN:  Did you rent a MicroFridge from us last year?

Please print the Form Confirmation page that appears after you submit the form.  It will be your only copy of this form.

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Copyright information goes here.
Last revised: June 25, 2008