Instructions
  Please fill out this form completely.

Once you click on the "Submit" button below, a Central representative will contact you within 48 hours.
Privacy Policy
CENTRAL Rent-To-Own Order Form
for Residents of
the Treasure Valley & Magic Valley
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PLEASE CHECK ANY ITEMS YOU MAY HAVE AN INTEREST IN:
Portable TV Washer/Dryer Microwave Living Room
Big Screen TV Refrigerator Stereo Dining Room
VCR Freezer Bedroom Computer
DVD Other:
Comments/Special Instructions:
 
Personal Information
Full Name: *  NickName:   Date of Birth: *
Soc. Sec. #: *   Driver's Lic. #: *   State: *
Current Residence
Address : * Apt. #:
City : * State : * Zip : *
How Long : * Phone #: *
In whose name is Telephone/UItilities:
Whose name on lease if rented :
Other
Cell # : E-Mail Address :
Mailing Address
Same as Current Residence Address
Address : City : State : Zip :
Landlord Information
Type : Name : * Address : *
City : * State : * Zip : * Phone #: *
Insurance Information
No Insurance...
Insurance Company : Insurance Agent : Insurance Agent Phone :
Previous Address
Have lived at current Residence for 3+ years...
Address : City : State : Zip :
How Long :
Vehicle Information
No Vehicle...
Car Make & Model : Car Year : Car Color :
Car License Plate # : State Registered :
Spouse/Roommate Information
None...
Name : Date of Birth :
Social Security # : Driver's License #:
Driver's License State :
Other Adult in Household Information
Name : Relation :
Employment Information
Unemployed/Social Security...
Employer : * Position : *
Type : * Length : * Hours/Week : *
Employer Address : * Employer City : *
Employer State : * Employer Zip : * Monthly Income :$ *
Pay Dates : * Supervisor : *
Employer Phone : *
Spouse/Roommate Employment Information
Unemployed/Social Security...
Employer : Occupation :
Employment Length : Hours/Week :
Employer Address : Employer City :
Employer State : Employer Zip : Monthly Income :$
Pay Dates : Supervisor Name:
Employer Phone :
Personal References
  Name Address City State Zip Phone Relation
1*
2*
3*
4
5
Another Rental Company
Have you ever rented from another rental company?
Rental Company Name : Year :
RELEASE OF INFORMATION TO CENTRAL (PLEASE READ BEFORE CONTINUING)
The information I have provided on this form is correct. I authorize confirmation of all infomration that I have provided.. You may conact any person or company that I have listed above and I fully release all parties from all liability for any damages that may result. My (our) typed name(s) below indicate that for purpose of confirmation, I (we) have voluntarily waived the protetion of all rights to privacy laws. This order may be rejected if any information provided above is found to be false.
Renter 1 Name : * Date : * 
Renter 2 Name : Date :
How did you hear about us?*
Customer Referral:
Newspaper Walk-In TV Direct Mail Yellow Pages
Former Customer Handbill Other:
* Fields must be complete before submitting this form...
 
 

 
 
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