ICA Clarinet Donation Intake Form
Donor Contact Information
Donor Name
*
First Name
Last Name
Contact Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Donation Information
Please fill in the information below to the best of your knowledge. If you are not sure about the instrument's condition or build, please be sure to include pictures of the brand logo, potential damage, and other identifiable markings in your photos.
Type of Clarinet
B-flat Clarinet
A Clarinet
E-Flat Clarinet
Bass Clarinet
Other
Instrument Material
Plastic/Resin
Wood
Other
Instrument Brand and Model
Instrument Serial Number
Condition of the Instrument and Repairs Needed
Examples: Age of the instrument, where it has been stored, any visible damage to the instrument, case, or accessories.
Please attach a photo of the instrument that contains all elements of the instrument in plain view, as well as the condition of the case.
*
Browse Files
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Are you able to willing to cover a portion of the repair costs?
Yes
No
Will you require a donation receipt?
*
Yes
No
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