Band Instrument Repair Pickup Request Form Step 1 of 3 - Student Information 0% If you are a current rental customer and would like to return your instrument (having it picked up at your school) during the school year, please select Rental Return Pickup and we will grab your instrument the next scheduled delivery to your school. As long as your rental payments are current, there is no fee or early return charge associated with canceling your contract. If you have an instrument that needs repaired, we can pick it up and have it repaired! You can arrange payment through the website or have us call you when it is completed. Your instrument will then be returned to the school, fixed up and ready to play!Service Requested*Rental Return PickupBand Instrument Repair Service STUDENT INFORMATION Student Name*Student Grade*Student School*A-C ValleyBlairsvilleBrockwayBrookvilleCameron CountyClarionClarion LimestoneClearfieldCurwensvilleCranberryDuboisEast and West ForestElk County CatholicFranklinHarmonyHomer CenterIndianaKeystoneMoshannon ValleyMarion CenterNorth ClarionNorthern CambriaOil CityPenns ManorPhilipsburgPurchase LinePunxsutawneyRedbankRocky GroveSt. BernardsSt FrancisSt. JosephsSt MarysUnionUnitedWest BranchSchool Building* BILLING INFORMATION Billing Information: Full Name*Email Address* Enter Email Confirm Email Primary Phone Number*Secondary Phone Number Instrument Type*Flute, Clarinet, Sax, etc.Problem Report*What is wrong with your instrument that needs fixed?Reason for Return*Purchased New Instrument ElsewherePurchased Used Instrument ElsewhereNot Continuing School Band ProgramPurchased Instrument From SpottsChanged IntsrumentsNotesFeel free to let us know what you thought of our rental program, if you experienced any problems, or if you had a great experience with us. We love to hear feedback so we can continue to improve our rental program. Payment Options*Pre-entering credit card information allows us to fix your instrument and deliver it our next trip. For any repair over $100: you will be contacted to complete the payment even when the card is pre-authorized. When pay by phone is selected, we will contact you after the service has been completed. *Be aware, we are unable to deliver the instrument until the repair is paid for, and if we are unable to contact you by phone prior to the next scheduled delivery date, delivery may be delayed*Pre-authorize Credit CardPay by PhoneM&R CoverageCredit Card Type*VisaMastercardDiscoverCredit Card Number*Expiration Date*3 Digit CVV Code on Back of Card*Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Authorization Agreement*By selecting "I agree" you are agreeing to let us pick your instrument up from the school listed, get the instrument in good working condition (fixing problems described), and you agree to pay for the services rendered. *There are no additional charges for delivery and pickup, just repair services rendered.I AGREE This iframe contains the logic required to handle Ajax powered Gravity Forms.