MINNESOTA
STATE UNIVERSITY MOORHEAD
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 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 3RD STREET SOUTH
· MOORHEAD,
MN 56560
(218) 233-5735 · Toll Free 1-866-57LOFTS
OR 1-866-575-6387 · www.csilofts.com