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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:

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City:

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Male Female

I am an EMT student I am a Paramedic student

Shirt Size Mens: Small Medium Large XL 2XL 3XL 4XL Ladies: Ldys XSmall Ldys Small Ldys Medium Ldys Large Ldys XL Ldys 2XL Ldys 3XL 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 --- 01 02 03 04 05 06 07 08 09 10 11 12 / ----- 2009 2010 2011 2012 2013 2014 2015 Visa Mastercard Discover American Express Would you like to receive emails from Genesys in the future? Yes No

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