Lagerquist Flute Service - Flute & Piccolo Instruction & Repair Services


    CREDIT  CARD   PAYMENT  FORM


    To make your payment, please complete and send the form below. This is a SECURED Form. Your name and e-mail address must be completed in order to insure that this form will reach us.

    If you do not wish to send this form via the Internet, you may also:

      1.  FAX:   -   complete this form,
                     -   print it (in black text option)
                     -   then fax it to us at (301) 927-9569.
      2.  PHONE:  (301) 779-7674 to verbally give us your order.

    A repair deposit is required.  MasterCard, VISA and American
    Express are accepted.

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

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    Charge Card Payment Information:

    Name on Credit Card:                
    Billing Address:
    City:
    State / Province:
    Zip Code:
    Country:
    Credit Card Type: MasterCard    Visa    American Express
    Credit Card #:
    Expiration Date:
    Email   (required):
    Phone:
    Fax (optional):


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Thank you for your payment.

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