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Genesys EMS Education - Uniform Orders

Please complete the form below completely. (Bolded fields are required.)

Please indicate below your preference of how your pledge should be listed.
Name:
Street Address:
City:
State:
Postal Code:
E-mail Address:
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Male Female
I am an EMT student I am a Paramedic student
 
Shirt Size
Small - 14 Small - 14.5
Med - 15 Med - 15.5
Large - 16 Large - 16.5
XL - 17 XL - 17.5
XXL - 18 XXL - 18.5
XXXL - 19 XXXL - 19.5

Long Sleeve
Short Sleeve

Quantity
(ex: 1 L Sleeve, 1 S Sleeve)
Waist size

Inseam

Quantity

The total price of each uniform (with tax) is $54.04. A charge for this amount will appear on your credit card statement from "Cintas."

Name (as it appears on the credit card)
Credit Card Number:
Expiration Date:Card Type
/

Visa,Mastercard, Discover, Amex

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