Applicant (Parent / Guardian)
Date: Instrument Desired:
Name:
Address:
Mailing Address: (if different)
City / State: Zip: (Required)
Buying or Renting Residence  How long there?
Home phone: Work phone: (Both Required)
Employer: How long there?
Visa MC Disc AmEx Exp. Date:
Credit Card #:
Applicants Drivers License #: (Required)
Applicants Social Security #: - - (Required)
Spouse:
Spouse's Employer:
Spouse Work Phone:
Nearest Relative NOT Living With You:
Relative's Phone:
Student Name:
Student's School:
Maintenace & Replacement Coverage at $4.00 additional per month? yes / no
Loaner Music Stand: yes / no
Music Book Desired:
Date Desired:
E-Mail Address:
Are you coming into one of our locations to pick-up the instrument?
Choose one only. Yes or No
Tennyson Denver Our Road-Rep to deliver

I am a legal resident of Colorado and 21 years of age or older.
Please allow 3 business days to process your applicaiton.

By pressing the "Submit" button you authorize Flesher-Hinton Music to investigate your credit in relation to the rental of the instrument indicated. You will be notified by a Flesher-Hinton Music Co. representative of your approval via phone call or email. Thanks for interest in renting with us.