Please fill in the form below, print the form, then call Denton Cottier & Daniels and let them
know you are faxing the form. A representative will supply the correct fax number to you.
Buffalo Store Tel: 716-689-6996 Rochester Store Tel: 585-586-3020
Which
store would you like to rent an instrument from? |
|
What
Acoustic piano do you wish to rent? |
|
What
Digital piano do you wish to rent? |
|
What
finish would you like on your Acoustic piano? |
|
What
style would you like for your Acoustic piano? |
|
If
you wish to use a credit card for the Rental Startup Fees, please provide the following information: |
|
Credit
Card |
|
Name
exactly as appears on card |
|
Card
Number |
|
Expiration
Date |
Month
Year |
Please provide the following personal information for your |
|
Name
(first, mid, last) |
|
E-mail
Address |
|
Address
(number \ street) |
|
Address
(cont.) |
|
City |
|
State |
|
Zip
/ Postal Code |
|
Telephone
(home) |
|
Telephone
(work) |
|
Social
Security Number |
|
Employer
Name |
|
Employer
Address |
|
Employer
City |
|
Employer
State |
|
Employer
Zip / Postal |
|
Employer
Telephone |
|
Employment
Length |
Years
Months |
Monthly
Gross Income |
$
|