CONCORDIA COLLEGE

SORRY, NO PHONE ORDERS

Print out this form and return it to College Services August 15th

( )  I would like to rent a bed loft with a side rail.  Enclosed is my $10.00 deposit.

( )  I would like to rent a bed loft with a side rail.  Enclosed is full payment of $90.00 ($80.00 + $10.00 deposit).

( )  I would like to rent a 14” x 10” shelf for my loft.  Enclosed is an additional $5.00.

PLEASE FURNISH ME WITH A:

Year  ( )            Semester  ( )                Enclosed is my:

2.0 CF Refrigerator for the:                   ( ) ( ) $10.00 Deposit or

Full payment of:  ( )$55/Year  ( )$35/Sem

3.6 CF Refrigerator for the:                   ( ) ( )  $10.00 Deposit or

                                                                                                                Full payment of:  ( )$75/Year  ( )$50/Sem

Please Print Clearly

NAME_______________________________________________________________________

RESIDENCE HALL ________________________________________ROOM #_____________

CELL/ROOM PHONE (_____)___________________HOME PHONE (_____)______________

HOME ADDRESS_____________________CITY_______________STATE_____ZIP________

CREDIT CARD PAYMENTS:

VISA               ( )            MASTERCARD            ( ) DISCOVER ( )

*Visa, MasterCard and Discover are the only credit cards accepted*

NAME OF CARDHOLDER:________________________ AMOUNT CHARGED:__________

CARD NUMBER:________________________________ EXPIRATION DATE:___________

CARDHOLDER ADDRESS:_____________________________________________________

______________________________________________________

CARDHOLDER SIGNATURE:_________________________________________________

MAKE CHECKS PAYABLE TO:   CSI

MAIL TO:  CSI · 1301 3^RD STREET SOUTH · MOORHEAD, MN 56560

(218) 233-5735     ·     Toll Free  1-866-57LOFTS   OR    1-866-575-6387     ·     www.csilofts.com