order form - University of Maryland School of Medicine

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University of Maryland Baltimore Faculty Regalia Rental **Please fill out everything as accurately as possible** Name: Phone Number and e-­‐mail address: Degree (exact wording): Institution where degree is from: Height: Weight: _____Bachelor set (cap/gown/tassel/hood) $66 _____Master set (cap/gown/tassel/hood) $70 _____Doctoral set (cap/gown/tassel/hood) $78 METHOD OF PAYMENT (all orders must be paid for at time of order): **All information MUST be filled out** Credit Card Number___________________________________ Expiration Date_______________ Security Code____________ Billing Zip Code________________________________ Signature____________________________________ Is this a University Purchasing Card (tax exempt)? ________ Fax number to fax copy of receipt _______________ Checks can be made payable to the UMB BOOKSTORE All orders must be received by April 13, 2016. Orders can be e-­‐mailed to [email protected] Please call if you have any questions (410-­‐328-­‐7788). 
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