Rental Form

Harmony Music / Fowler Music Service

Anne Arundel County, Maryland

Rental Agreement

Special! 2nd and 3rd month FREE!

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All fields required.

Personal Information:

First Name:

Last Name:

Address:

City: State: Zip:

Home Phone:

Driver's License # OR Soc Sec #:

Employer:

Work Phone: Position:

Alternate Contact #1: Phone #:

Alternate Contact #2: Phone #:

Email Address (for company contact only):

Student's Name:

School:

We will deliver to schools on the above list. Others are welcome to pre-order their instrument and pick it up at our shop.

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Instrument Info and Monthly Charges:

Special! 2nd and 3rd month FREE!

Select Instrument and monthly charge:

Optional Protection Plan covers the instrument against 3 specific cases of theft - see Item 12 below - $5.00 / month YESNO

Optional Damage Coverage covers the instrument for up to $275 of damage - see Item 13 below - $5.00 / month YESNO

Credit Card Information:

Card Number: Exp:

Name as it appears on Card:

Bill my card monthly

Terms and Agreements:

I agree to the above Terms and Agreements and agree to pay the selected costs as indicated above.

HARMONY MUSIC FOWLER MUSIC SERVICE

17725 N.E. 65th Street #B235 8370 B&A Blvd. (at Wishing Well Florist)

Redmond, WA 98052 Pasadena, MD 21122

800-356-2826 410-647-9537