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      Today's Date:      
      What Instrument are you interested in?


      Applicant's Information

Check one:  Mr.     Mrs.     Ms.     Miss
First Name:     Middle Initial:     Last Name:
Over 18? (check if "yes")     Relationship to Student:
Applicant's Address:
City:     State:     Zip Code:
How long have you resided at your current address? Years Months
Work Telephone Number:
Home Telephone Number:
Cellular Telephone Number:
Social Security #:
Driver's License Number:     State (if not Ind.):
Applicant's Employer's Company Name:
How Long?     Company Position:
Hours at Work:   until  
Other Income $  per     from  
Home:  Rent     Own
E-mail Address:


Spouse's Info

First Name:     Middle Initial:     Last Name:
Spouse's Employer:     Position:
Socisl Security #:
Work Telephone Number:
Cellular Telephone Number:
Other Income $  per     from  


Student's Info

First Name:     Middle Initial:     Last Name:
School:
Student's Address IF Different From Applicant's:
Address:
City:     State:     Zip Code:
Guardian's Name at this Address:


Personal Reference (relative NOT living with you)

Name:     Relationship:
Address:
City: State: Zip:
Telephone Number:


Credit Information

Major Credit Card Type:
Credit Card Number:
Expiration Date:     3-Digit Security Code:
Bank Name:
I authorize monthly payments using this charge card: (check if "yes")

I understand that my credit report will be reviewed by musicians' repair & sales, and will be held in strict confidence. This information will be transmitted via an encrypted Secure Socket Layer (SSL)
connection and will not be shared with anyone or used for any other purpose.