Central Rent to Own - Order Form

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 <

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...