PYXIS SCRUBSTATION ACCESS for U of M – Karen Holmes

PYXIS SCRUBSTATION ACCESS for U of M – Karen Holmes
Please PRINT clearly. Incomplete or illegible forms will be returned.
First Name:
Student #: ________________________
Last Name:
Email:
Start date: __________________________
End date: ________________________
__________________________
DEPOSIT RECEIVED - $25 per set of scrubs (please circle):
Credit Card
/
Personal Cheque
***Access will not be granted without a deposit. If paying by cheque, there must be separate cheques
for each scrub suit issued and the cheques must be dated for the last day of the term.
Access is requested for the following (please circle):




Adult O.R.
/
Children’s O.R.
It is the responsibility of the user to monitor their account and understand how to utilize the
Scrubstation. Any questions about usage may be directed to Carl White at [email protected].
Issues with credits must be reported to Carl White by email ([email protected]) no later than
48 hours after the event. Issues reported after that time will not be addressed and the user will
remain at their current credit limit until payment is made.
All scrubs are to be returned within 48 hours of the last day to avoid a fee. There will not be a
reminder sent as that date is the responsibility of the user.
If there is an issue with payment, a hold will be placed on the users student account with the
Registrar’s Office and all scrub privileges will be suspended.
Each authorized user who is issued access is responsible for the control of that access and will be held
accountable for all use of that access including financial responsibility for theft and disciplinary action
related to sharing, loaning, or other use for unauthorized access.
I have read and understand the above statements.
_____________________________
_______________________
Student
Karen Holmes
/
Date
/
Date
This form may be emailed to Karen Holmes ([email protected]) or faxed to 204-787-4837
Revised May 2014
CREDIT CARD PAYMENT FORM
Date: __________________________
HSC Invoice Number: _____________
Credit Cost Centre: 10400074 / 549510000
Credit Card Information
Card Type:
VISA
/
MasterCard
/
American Express
/ Other (please list)
Name (as it appears on the card): ______________________________________
Card #: __________________________________
Expiry Date: ________________
CCID / CVC # (typically 3 digits found on the back of the card): _____________
Signature: ____________________________________________
By signing this form, I give approval for HSC to charge for the outstanding scrubs on my account at the rate of
$25.00 each, per the previously signed PYXIS Scrubstation Access agreement.
Revised May 2014