Student Repair Pickup Request Form Fill out and print this form and we'll be looking for your repair on our next trip! *delivery is typically weekly, though times and days are subject to change. See our school delivery information page to view schools we visit. Step 1 of 3 - Student Information 0% STUDENT INFORMATION Student Name* Student Grade* Student School*BlairsvilleBrockwayBrookvilleCameron CountyClarionClarion LimestoneClearfieldCurwensvilleCranberryDuboisEast and West ForestElk County CatholicFranklinHarmonyHomer CenterIndianaJohnsonburgKeystoneMoshannon 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 Cell Phone Number*Secondary Phone Number Instrument Type*Flute, Clarinet, Sax, etc. Instrument Makeexamples - "King" "Selmer" etc. Serial NumberSerial numbers are listed on the instrument (like a car's vin number), if you can't find it, just leave this blank. Problem Report*What is wrong with your instrument that needs fixed?Payment Options*Pre-entering credit card information allows us to fix your instrument and deliver it our next trip. For any repair over $150: 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 Card Pay by Phone M&R Coverage Credit Card Type*VisaMastercardDiscoverCredit Card Number* Expiration Date*MM/YYYY 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 Notes/OtherAuthorization 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 *AFTER SUBMITTING THIS FORM, please PRINT the information page that follows and include it with your instrument. If you don't have a printer, please fill out a piece of paper and include the information listed on the page. This will help us keep track of your instrument. Thank you!