8/14/2019 eligibility orderform

http://slidepdf.com/reader/full/eligibility-orderform 1/3

 Order Request Form

**Employee Use Only** 

Employee #: __________________ Invoice #: _____________________

Shipping Charge: $_____________ Date Invoiced: _________________

FedEx Tracking #: __________________________________________________

UPS Tracking #: ___________________________________________________

Step 1: Please neatly print out the following information. Date: ____________________ 

Customer Name: _______________________________________ BruinCard #: _______________

Shipping Address:

Contact Phone Number: Credit Card Information:

Daytime: _________________________ Cardholder Name: ___________________________ 

Evening: _________________________ CC #: ______________________________________Drivers

Exp: _________ Type: __________  License #: ______________

Step 2: Please enter the items you want shipped to you. If possible, specify whether it is for PC

or Mac, the version number of any software, or any other specifics so we can more easilyprocess your order. You will be notified of the shipping fee after the Shipping Request isreceived.

Products to be shipped:

Special Instructions:

I authorize the UCLA Computer Store to charge the products listed above, applicable tax, and shipping charges to the credit cardnumber provided and hereby agree to pay the total amount according to the card issuer agreement. I further authorize the individual

identified as “the Customer” to accept this order.

Signature - X____________________________________________ Continued on next page ->

8/14/2019 eligibility orderform

http://slidepdf.com/reader/full/eligibility-orderform 2/3

 

Step 3: This page need only be filled out if you are purchasing an Apple computer. Please

read and sign the eligibility form below. This page is used so that you may understand theeligibility restrictions on the purchase of Apple computers from the UCLA Store. If thisshipping request is for any other product you may skip to the next step.

I certify that I meet the eligibility requirements marked below: (Check one only.)

I am a student who is enrolled in a course of study leading to a degree or certificatefrom the University of California, Los Angeles (hereinafter referred to as the Institution).

I am an entering student who has graduated from high school, been accepted tothe Institution, signed a letter of intent to enroll, and submitted a non-refundabledeposit or payment to the institution.

I am a faculty member at the Institution.

I am a staff member who is directly associated with the Institution’s academicmission and am not employed on a temporary basis, employed as a contractor, or acting as a consultant on behalf of the Institution.

By signing below, I certify that:

1. The Apple products I am purchasing through the Institution’s CollegiatePartnership Program Agreement with Apple Computer, Inc. are for my ownpersonal, educational, and/or research use.

2. I am not purchasing the Apple products for the purpose of further resale.

INDIVIDUAL CERTIFICATION:

Individual’s Signature Date

  ________________________________ ____________________________

Print Name I.D. Number 

  ________________________________ ____________________________

Continued on next page ->

8/14/2019 eligibility orderform

http://slidepdf.com/reader/full/eligibility-orderform 3/3

 

Step 4: Put together the paperwork needed to process your order. Three things are required: a

copy of the cardholder’s driver’s license, a copy of the credit card that will be used (Visa, MasterCard,Discover, or AmEx), and a copy of the BruinCard or academic ID from the eligible party.

Privacy Notice: Personal information is maintained for supplier audits only. The UCLA Store will not disclose anyinformation to 3

rdparties. Signature will be kept on file.

Sample:

Step 5: Fax in your request. To process your order we will need Page 1 from this form and the

paperwork created in Steps 3 and 4. Please fax all of these papers to the UCLA Computer Store. After faxing in the order, call the store to verify the receipt of your order and to

determine the shipping charge on your order. Please call if there are any questions regardingthis procedure.

Phone: (310) 825-6952Fax: (310) 206-0637