Name: Musical Instrument Rentals
Price: 0.50 USD
Availability: InStock

Customer Information

Name*

First Last

Email*

Phone*

Driver's License Number*

Address*

Street Address Address Line 2 City State ZIP Code

Number of instruments to try.

1
2
3

Instrument Information 1

Instrument 1*

Ex)Violin

Manufacturer*

Model Number*

Condition*

Brand New
Used

Serial Number*

Sale price*

Instrument Information 2

Instrument 2*

Ex)Violin

Manufacturer*

Model Number*

Condition*

Brand New
Used

Serial Number*

Sale price*

Instrument Information 3

Instrument 3*

Ex)Violin

Manufacturer*

Model Number*

Condition*

Brand New
Used

Serial Number*

Sale price*

Terms and Conditions

Return Due Date*

Payment*

I will try the listed instrument before make final decision to purchase*

Payment*

I will return the listed instrument(s) in new condition without any damages on or before the return due date if I do not satisfy. with the trial instrument(s)*

Consent*

I authorize Centreville Music Shop charge the total instrument price and sales tax with credit card that I provided if I do not return the instrument within trial period.*

Consent*

I agree that I will purchase the damaged instrument if I make any damage.*

Total Trial Instrument Value( 6% sales tax will be added).

Customer has business relationship with Centreville Music more than 6 months ?*

Yes
No

Customer has a referral from any teachers?*

Yes
No

Name of the teacher or customer who referred.*

Phone number of the person who referred.

Refundable security deposit

Price: $0.00

Customer's Signature*

Phone

This field is for validation purposes and should be left unchanged.

Instrument Trial Authorization

Customer Information

Instrument Information 1

Instrument Information 2

Instrument Information 3

Terms and Conditions

Related products

Instrument Payoff