GNSC 170/171 MATERIALS ORDER FORM Name: ___________________________________ Email address : ______________ Social Security #: _____________________________________________________ Address: ____________________________________________________________ City: ____________________________________ State: ___________ Zip: _______ (Please note: UPS will not deliver to a post office box.) (_____) _____________________ (_______) _______________________ Daytime Phone Evening Phone Please check mark (3) for the following items that you would like to order: r GNSC 170 Videotape Rental, "Weather Hazards"* at $70.00 each.   $______ r GNSC 171 Lab Kit Purchase at $8.10 each   ______ Sales tax (MD Residents only: $3.50 for videotape, 40¢ for lab kits).    ______ (MD Residents total: $82; non-MD Residents: $78.10) TOTAL: $______ *Refund of $40 will be generated upon return of videotape, plus $2 sales tax for MD residents only. $5 is charged if tapes need rewinding or packaging is missing. Payment may be made using VISA, Master Card, money order, personal check, bank cashier’s check or certified check. Please complete the following if using charge card: r Money Order Account #: ________________________________ r Cashier’s/Certified Check Name on Card: ____________________________ r Personal Check Expiration Date: ____________________________ r VISA Amount of Charge: _________________________ r Master Card _________________________________________ Cardholder’s Signature                                      Date Completed order form may be mailed to: University of Maryland University College The Learning Marketplace, SFSC Room 1210 3501 University Blvd. East Adelphi, MD 20783-8095 or faxed to: 301-985-7496 For additional information, please call 301-985-7112, or email Learningmktplc@umuc.edu Orders will be accepted by mail or fax. Please allow two weeks for delivery.

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