MUSIC HOUSE - WALK-IN CUSTOMER SUBMISSION FORM

Rental Instrument : CLARINET <AlmostNew>
Before you fill out this form you should have given the customer a RENTAL CONTRACT. Only after the customer has filled out a rental contract should this form be submitted. Fill out the information in this form from the RENTAL CONTRACT.
per/mo  checks are not accepted <cc only>  
Base Rent
25    
Use Tax
2.00 add Theft & Damage Coverage ?
TOTAL
      $ 5.00 per/mo yes no    

This REQUIRES a PAPER CONTRACT filled out by the customer !
    < DID CUST FILL OUT A PAPER CONTRACT?   CLARINET <AlmostNew>  
    < ENTER INST SERIAL #  

Renters 1st Name:

< fill the information out with information provided by customer < from a rental contract you should have provided the customer  
Last Name:
May I have your HOME ADDRESS:
Su DOMICILIO:
May I have the CITY YOU LIVE IN:
y la CUIDAD: 

*PO BOX NOT ACCEPTED
and the STATE . . . (y el estado) ZIP > (y el codigo postal  
and your EMAIL:
  Ph #: ( ) -  
Credit/Debit Card Information Accepted Cards
( Required for 1st Month Payment )
Card # Expiration: mo yr - ex:09 03
Cardholder Name: check if same as above > first   last
Acct will be Autobilled unless checked for "Mail-In Payments "
< Prefers to Mail-In Pymts
. . .AUTOBILL . Credit Card/Debit Card>

location: MH CORPORATE STORE & REPAIR

Todays Date:

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