Instrument Rental Agreement

Parent/Guardian Name Student Name

School District
School Building
Grade
Email Address
Instrument

Instrument Choice

(choose one)

Flute
Clarinet
Trumpet
Trombone
Bell Kit
Snare Drum Kit
Combo Kit
Wood Clarinet
Alto Saxophone
Practice Pad Kit (purchase)

Midstate Protection plan is $6 for all of the above except
Wood Clarinet and Alto Saxophone, which are $8

Payment

Initial Payment*  
*Includes MIDSTATE Protection Plan $6 or $8  
Sales Tax (8%)  
Total  

I understand and agree to all of the terms and conditions of this
contract.

I do hereby authorize Midstate Music of CNY, Inc. to initiate
recurring debit entries to my credit/debit card account or
checking/savings account each month on the date indicated.
I acknowledge that the origination of ACH transactions
to my account must comply with the provisions of US law.

Order subject to credit approval. For a record of your order,
please print this page before submitting. (you are leaving this page).