Repair Order & Credit Card Payment Form



To request repair service for your flute and/or piccolo and make payment, please complete and send the form below. A repair deposit is required. MasterCard, VISA and Discover are accepted.

Your name and e-mail address must be completed in order to ensure that this form will reach me. If you do not wish to send this form via the Internet, you may also:

    1.  FAX:  -   complete this form,
                   -   print it
                   -   then fax it to me at (301) 927-9569.
    2.  PHONE:  (301) 775-5242 to verbally give me your order.

Please be assured that all information you give me will be held in the strictest confidence and will not be shared with anyone else.


Name:    (required)
E-mail address:    (required)
Title:
Type of Business:
Business/Organization: 
Address:
City:
State or Province:
Zip Code:
Country:
Phone:
Fax (optional):
How did you find this Web site:

Instrument: Flute         Age:  
                      Metal      Wood      French      Plateau     
                      B-Foot    C-Foot    Adjustment Screws
Piccolo     Age:    
                      Metal      Wood

Repair Needed:    
Overhaul      Clean-Oil-Adjust      Play-Condition     

Pads to Use:
Straubinger or Schmidt      Conventional

Additional Information / Comments:



Credit Card Payment Information


Name on Credit Card:
Billing Address: (if different from above)
City:
State / Province:
Zip Code:
Country:
Credit Card Type: MasterCard     Visa     Discover
Credit Card #:
Expiration Date:

Thank you for your repair order request and payment. I will respond to you shortly.