First, Last Name	Initial
Spouse's First, Last Name	Initial
Street address	Apt #
City	Province Postal Code
Home Phone	Work Phone
Email Address
Verify Email Address
Employer	How Long
Drivers License #	Date of Birth / Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Credit Card	VI  MC  #  - - - Exp /    I don't have a credit card
Three digit verification code	What is this?
Name on credit card
Student's First, Last Name	Initial
Student's School	Please choose school name A. Lorne Cassidy ES Ashbury College A. Y. Jackson SS Beatrice-Desloges Catholic HS Bell HS Bridlewood Community ES Broadview PS Brookfield HS Canterbury HS Cairine Wilson SS Carleton Heights PS Castor Valley ES Castlefrank ES Cedarview MS Colonel By SS D. Aubrey Moodie MS D. Roy Kennedy PS Dunning-Foubert ES Earl of March SS Emily Carr MS Featherston Drive PS Fielding Drive PS Fitzroy Centennial PS Glashan PS Glebe CI Gloucester HS Goulbourn MS Greenbank MS Henry Larson ES Henry Munroe MS Hopewell Avenue PS Huntley Centennial PS Jack Donohue PS J. H. Putman PS John McCrae SS J. S. Woodworth SS Katimavik ES Lisgar CI Longfields-Davidson Heights IS Maple Ridge ES Merivale HS Metcalfe PS Mother Theresa Catholic HS Nepean HS Opeongo HS Rideau Valley MS Roberta Bondar PS Sir Winston Churchill PS South Carleton HS Stephen Leacock PS Steve MacLean PS St. Joseph's HS St. Patrick's HS St. Paul ES Stonecrest ES Trillium ES W. Erskine Johnston PS W. O. Mitchell ES Woodroffe HS Other (Please specify)
Teacher	Grade (Going into in September)
Instrument Requested	Please choose instrument Acoustic Guitar Alto Saxophone Banjo Baritone Baritone Saxophone Bassoon Bell Kit Clarinet Clarinet (Bass) Cornet Drum Set Euphonium Flugelhorn Flute French Horn (Double) French Horn (Single) Oboe Piccolo Soprano Saxophone Tenor Saxophone Trombone Trombone (Bass) Tuba Trumpet String Bass (Upright)
Referral Customer's Last Name	Home Phone #