Fillable Printable Student Personal Identification Cards Order Form - Michigan

Student Personal Identification Cards Order Form - Michigan

PLEASE NOTE: A Copy Center requisition Form MUST accompany this form.

title

name

dept.

STUDENT PERSONAL IDENTIFICATION CARDS ORDER FORM

Form fields below are computer interactive (for typing)

University of Michigan Copy Center

1919 Green Road, Ann Arbor, Michigan 48109-2564 • Telephone: 647-0507 • FAX: 647-5473

[email protected]

Please print or type information on the above form EXACTLY as you wish it to be printed

(i.e., capitals and lower case).

school University of Michigan,

address 1

address 2

phone/fax

e-mail

Jane Doe

Ph.D. Candidate

Chemical Engineering

University of Michigan, College of Engineering

3074 H. H. Dow Building, 2300 Hayward

Ann Arbor, MI 48109-2136

734-000-0000 FAX 734-000-0000

[email protected]

Conditions of Use

University of Michigan Student Personal Identification Cards

The University of Michigan “Block M” is an official trademark of the University of Michigan. The University of

Michigan grants individual students the right to use the Block M on personal identification cards, provided that

students adhere to the following conditions:

1. Students must use the standard card design.

2. Cardholders may not photocopy, scan, alter, or otherwise use the Block M Logo independently for

any purpose whatsoever without the express permission of the Office of the Vice President for

Communications of the University of Michigan.

3. Student personal identification cards may be used only for purposes directly related to the student’s

attendance at, or graduation from, the University of Michigan. The personal identification cards may not

be used for the student’s own business or personal purposes, or for any other purposes.

4. Valid University of Michigan student identification must be presented to the printer at the time the cards

are ordered.

I agree to accept the terms and conditions for use of the University of Michigan Block M on

my personal identification cards as outlined above.

Signed: __________________________________________ Date: ___________________________

Name (please print) _________________________________________________________________

Address: __________________________________________________________________________

Telephone:_________________________________ Expected graduation date:__________________

To be completed by printer

: The required items in number 4 above has been presented to me.

Printing company:

____________________________________

Salesperson:

_____________________________

Printer: Please return signed white copy to: University of Michigan

Office of the Vice President for Communications

2040 Fleming Administration Building

Ann Arbor, MI 48109-1340

Phone: (734) 763-5800; Fax: (734) 936-0775

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Date: ___________________

Depart

ment: __________________________________________________________

□ Charge to ShortCode __________________________

□ Will pay with Cash (pick-up only: sales tax will be added, NO checks or credit cards allowed)

1919 Green Road

Ann Arbor, MI 48109-2564

ph: (734) 647-0507

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x-cc-ccaux@umich.edu

tp://mbiz.bf.umich.edu

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This form is to accompany the STUDENT PERSONAL IDENTIFICATION CARDS ORDER FORM and the CONDITIONS OF USE FORM.

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Name ____________________________________________________

Rm / Bldg. ________________________________________________

Campus Zip ________________

Street Address ____________________________________________

City __________________________ State ______ Zip ____________

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_________________________ __________________________

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(complete if different than Contact Person)

Name ____________________________________________________

Rm / Bldg. ________________________________________________

Campus Zip ________________

Street Address ____________________________________________

City __________________________ State ______ Zip ____________

I certify that the terms, restrictions, and qualifications set forth in this form’s administration policy are met and that that the payments are in compliance

with all conditions imposed by the funding source.

SSiiggnneedd

_________________________________________________

     Head of Department or Authorized Representative

ORDER QUANTITIES OF: 50 = $17 or 100 = $25 or 200 = $30

A PDF proof will be e-mailed to:

If paying with cash and not shortcode, please bring

exact change when picking up your cards.

Sales tax will be added to your order.

No credit cards or checks accepted.

Nov 2013