This form works best with Safari or Chrome. Please do not use other internet browsers. Renter InformationPC Member Name* First Last Age*Phone*Email* Enter Email Confirm Email Parent InformationParent/Guardian Name First Last PhoneEmail Enter Email Confirm Email InstrumentInstrument*Select...Trumpet (Value: $1,100)Mellophone (Value: $1,800)Euphonium (Value: $2,800)Tuba (Value: $4,000)Serial Number*Found on second valve casingCase Number (If Applicable)Note: Not all cases are numberedRental Contract TermsMaintenance* I/We agreeI/We, the undersigned, agree to be responsible for the musical instrument listed above, which is owned by Pacific Crest Youth Arts Organization (PCYAO). It is my/our responsibility to maintain the current condition of the instrument and case listed above. I/We understand that repair due to natural “wear and tear” of the instrument will be handled by PCYAO. I/We also understand that any damage or loss caused by misuse, abuse, or negligence on my/our part will be the responsibility of the renter and/or parent/guardian.Term of Rental* I/We agreeThis rental agreement is effective the date signed, and extends through the end of the Pacific Crest Drum and Bugle Corps Audition Weekend, held in December 2020 (date to be determined). It is my/our responsibility to return the instrument to PCYAO on or before the end of this agreement.Price* I/We AgreeThe rental fee totals $200. This can be paid in (1) eight monthly payments of $25, or (2) one single payment now of $175, which represents a savings of one month of rental.Member (Renter) Signature*Enter full name.Parent Signature*Enter full name.Signature* I/We AcceptI/We understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms of the Pacific Crest Instrument Rental Contract.PaymentPayment Method*Prepaid to my credit card ($175)Prepaid against my refund ($175)8 monthly charges of $25 to my credit cardPrepay Rental Price: $175.00 Credit card to be charged one-time fee of $175.Charge Against Refund Price: $175.00 One-time charge of $175 to be applied against Pacific Crest member's account.8 Monthly Charges Price: $25.00 Credit card will be automatically charged one time per month for $25.Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name Cardholder Billing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cardholder Email* Enter Email Confirm Email CAPTCHACredit card approval requires that the billing address, including Zip code, match the information on your credit card billing statement. This iframe contains the logic required to handle Ajax powered Gravity Forms.
