| Assisted Instrument | Purchase Scheme | |
| Application | Form. | |
| NAME OF PARENT/GUARDIAN: | SCHOOL: | |
| ADDRESS | ADDRESS: | |
| POSTCODE: | POSTCODE | |
| TELEPHONE: | TELEPHONE: | |
| PUPIL'S NAME: | ||
| INSTRUMENTAL TEACHER'S NAME: | ||
| MAKE OF INSTRUMENT: | MODEL: | |
| AMOUNT PAYABLE: | ||
| The above pupil fulfils the criteria laid down by | ||
| H.M. Customs & Excise, and is therefore eligible for the | ||
| Assisted Instrument Purchase Scheme | ||
| HEADTEACHER'S SIGNATURE: | ||
| INSTRUMENTAL TEACHER'S SIGNATURE: | ||
| PARENT/GUARDIAN'S SIGNATURE: | ||