Required Fields marked with * Customer Information Location * Alton, IL Anna, IL Batesville, AR Belleville, IL Benton, IL Blytheville, AR Brownsville, TN Cape Girardeau, MO Carmi, IL Caruthersville, MO Centralia, IL Chester, IL Crystal City, MO Decatur, IL Dexter, MO DuQuoin, IL Dyersburg, TN Evansville, IN Fairfield, IL Fairview Heights, IL Flora, IL Florissant, MO Fort Smith, AR Granite City, IL Hannibal, MO Harrisburg, IL Henderson, KY Herrin, IL Hoxie, AR Humboldt, TN Huntingdon, TN Independence, MO Jackson, TN Jacksonville, AR Jacksonville, IL Jerseyville, IL Jonesboro (North), AR Jonesboro (South), AR Kennett, MO Kirksville, MO Lawrenceville, IL Lawton, OK Lexington, TN Lincoln, IL Litchfield, IL Little Rock, AR Macon, MO Madisonville, KY Malden, MO Marion, IL Mattoon, IL Mayfield, KY Metropolis, IL Moberly, MO Mt. Carmel, IL Mt. Vernon, IL Murray, KY Muskogee, OK Newport, AR Oklahoma City, OK Olney, IL Osceola, AR Owensboro, KY Paducah KY Paragould, AR Peoria, IL (Prospect Blvd) Pocahontas, AR Poplar Bluff, MO Quincy, IL Robinson, IL Salem, IL Salem, MO Salina, KS Searcy, AR Sikeston, MO Sparta, IL Springfield, IL (Stevenson Dr) St. Charles, MO St. Joseph, MO St. Louis, MO (Dunn Road) St. Louis, MO (North Oaks Plaza) St. Louis, MO (Page Ave) St. Louis, MO (South Kingshighway) St. Robert, MO Sullivan, MO Taylorville, IL Troy, MO Trumann, AR Tulsa, OK Union, MO Vincennes, IN Warr Acres, OK Warrenton, MO Washington, MO West Frankfort, IL West Plains, MO Wichita (S Oliver) Wynne, AR First Name * Last Name * Email Address * Phone Number * Work Phone Number Date of Birth (MM/DD/YYYY) * Last 4 of SSN * Address * City * State *Select a state Alabama Alaska Arizona Arkansas Armed Forces Armed Forces America Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode * Income and Housing Employer * Employer Phone Number * Employer State *Select a state Alabama Alaska Arizona Arkansas Armed Forces Armed Forces America Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Job Title * Hire Date * Monthly Income * Pay Day Pay Period Other Income Monthly Rental/Payment Amount * Landlord Name * Landlord Phone Number * Years at Residence * Reference 1 Full Name * City * State *Select a state Alabama Alaska Arizona Arkansas Armed Forces Armed Forces Pacific Armed Forces America California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Relationship * Phone Number * Reference 2 Full Name * City * State *Select a state Alabama Alaska Arizona Arkansas Armed Forces Armed Forces Pacific Armed Forces America California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Relationship * Phone Number * Reference 3 Full Name * City * State *Select a state Alabama Alaska Arizona Arkansas Armed Forces Armed Forces Pacific Armed Forces America California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Relationship * Phone Number * Reference 4 Full Name * City * State *Select a state Alabama Alaska Arizona Arkansas Armed Forces Armed Forces Pacific Armed Forces America California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Relationship * Phone Number * PLEASE READ THIS STATEMENT BEFORE SIGNING I promise that the information I have provided on this form is correct. I authorize complete verification of all information I have provided. You may contact any person or company listed above and I fully release all parties from liability for any damage that may result. My (our) signature(s) indicates that for purposes of verification, I (we) have voluntarily waived the protection of all rights to privacy laws. This order may be rejected if any information provided is found to be false. By providing your contact information, you consent to receive emails from Rent One which may include emails related to payments or advertisements, receive texts from Rent One which may include texts related to payments or advertisements, and receive telephone calls from Rent One that may include prerecorded messages on behalf of Rent One related to payments or advertisements. RELEASE OF INFORMATION TO RENT ONE By your signature below, whether one or more applicants, you also agree to allow Rent One employees to contact the references listed above and your employer(s) to verify your information and to assist Rent One in its collection efforts if you fail to renew the rental agreement or return the merchandise to Rent One on time. This waiver is valid until you revoke it by notifying Rent One in writing by certified mail. I have read and understand these statements. This Electronic Signature Consent (“Consent”) sets forth the terms of my consent to sign documents electronically through the Rent One Signature System (“System”). I may decline to electronically sign any document. I may contact Rent One and request a paper copy of any document signed electronically through the System. I understand that (i) electronically signing any documents(s) legally binds me in the same manner as if I had signed in a non-electronic form, and (ii) the electronically stored copy of my signature, is considered to be the accurate and complete record, legally enforceable in any proceedings to the same extent as if such documents were originally generated in printed form. I agree not to contest the admissibility or enforceability of Rent One's electronically stored copy of this Consent and any other documents. By using the System to electronically sign and submit any document, I agree to the terms and conditions of this Consent. Renter signature * Signature date * NOTE: ALL APPLICATIONS MUST BE VERIFIED BY STORE MANAGER BEFORE RENTAL-APPLICATION CAN BE APPROVED.
