NORTH DAKOTA STATE UNIVERSITY

SORRY, NO PHONE ORDERS

Print out this form and return it to College Services by 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 for the:  (  )         (  )       (  )    $10.00 Deposit or Full payment of:    (  )$50/Year  (  )$35/Sem

3.6 CF for the:   (  )          (  )          (  )    $10.00 Deposit or Full payment of:     (  )$75/Year  (  )$50/Sem

Microwave:       (  )          (  )      (  )    $10.00 Deposit or Full payment of:     (  )$50/Year  (  )$35/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 3RD STREET SOUTH · MOORHEAD, MN 56560

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