MINNESOTA
STATE UNIVERSITY MOORHEAD
SORRY,
NO PHONE ORDERS
Print
out this form and return it to College Services August 14th
( )
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 ( )
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