| Your Name: | .............................................................................................. |
| Address: | .............................................................................................. |
| Town: | .............................................................................................. |
| Province / District: | .............................................................................................. |
| Country: | .............................................................................................. |
| Post / Zip code: | .............................................................................................. |
| Tel: | .............................................................................................. |
| Type of piano: | Square __ Cabinet __ Upright __ Cottage __ Grand __ |
| Serial number: | .............................................................................................. |
| Name on fall board: | ___ John Broadwood ___ John Broadwood & Son ___ John Broadwood & Sons ___ John Broadwood & Sons Ltd |
| Number of octaves: | .............................................................................................. |
| Compass: | .............................................................................................. |
| If your piano is a grand: | Overall Width ___ Overall Length ___ |
| Please send this form plus your cheque to: | John Broadwood & Sons Ltd. John Broadwood & Sons Ltd. Finchcocks Goudhurst Kent England. TN17 1HH |