Instrument Repair Permission Slip

Fill out this form if you would like Mr. Kalas to arrange to have your child’s instrument repaired by LUSCOMBE MUSIC.  Instruments must be given to Mr. Kalas on Tuesday morning before 9AM.  You will be billed at the address you provide below.

 

Student’s Name (please print) ____________________________

 

BILLING ADDRESS

____________________________________
Name

____________________________________
Street

____________________________________
City, State, Zip

____________________________________
Telephone number

______If you are already renting from Luscombe you may be paying a maintenance fee which would cover the cost of repairs.  Check here if you think that is true.

 

______Check here if you would like to be called with an estimate.

 

____________________________________
Signature

 

Below will be completed by Mr. Kalas

 

Instrument___________________________

 

Problem_____________________________