Customer Order FormShop and put together a list of items from these retailers we buy from.Exact model/product/pricing may not be available but Kevin will work with you to find your perfect fit.American Wholesale FurnitureVIEWCoaster FurnitureVIEWGE AppliancesVIEWLG AppliancesVIEWHP ComputersVIEWSamsungVIEWSymbol MattressesVIEWNoctova SleepVIEW Customer Order Form PERSONAL INFORMATION Email Date Referred by Name Birthday Sex Male Female Social Security # Driver's License # Address Apt./Floor City State Zip Residence Choose one Owned Rented House Apartment Other How long at this address? Utilities in whose name Phone # Work Phone Job Title Employer Work Address Hire Date Department Working Choose One Full Time Part Time Not Working Paid Choose One Once A Week Every Two Weeks Once A Month Take Home Pay Day Of Week Paid What is your annual household income? Choose One Under $8,000 $8,000 - $9,999 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $24,999 $25,000 - $29,999 $30,000 - $34,999 $35,000 - $39,999 $40,000 - $44,999 $45,000 or more HOUSEHOLD INFORMATION Name of Other Adult in Household Relationship Social Security # Job Title Employer Work Address Hire Date Shift Plant Department Supervisor Phone # with Ext. # PERSONAL REFERENCES Name, Address, City, State, ZIP, Phone #, Relationship Add each value on a separate line Name, Address, City, State, ZIP, Phone #, Relationship Add each value on a separate line Name, Address, City, State, ZIP, Phone #, Relationship Add each value on a separate line Name, Address, City, State, ZIP, Phone #, Relationship Add each value on a separate line Name, Address, City, State, ZIP, Phone #, Relationship Add each value on a separate line Name, Address, City, State, ZIP, Phone #, Relationship Add each value on a separate line OTHER INFORMATION Have you rented from any other companies? Yes No Other companies you are have rented from Other companies you are have rented from How did you first hear about us? TV AD Radio AD Brochure Newspaper AD Yellow Pages Billboard Magazine AD Other Person Passing By Other (Explain below) Other RELEASE OF ADDRESS (LOCATION) INFORMATION TO OUT THE DOOR RENT TO OWN Renter 1 Renter 2 Date The undersigned below hereby consent(s) to the release of information concerning my (our) address or location to Out The Door Rent To Own. In particular, this release shall permit the disclosure to Out The Door Rent To Own of such information regarding the undersigned in the possession of any agency or department of any state government of the United States of America, or of any other person or agency, or my (our) current or past employer. This release shall be effective for 24 months from the date below. I (we) understand that certain state and federal laws exist which protect my (our) right to privacy by restricting access to state and federal agency files, or files held by third parties. My (our) digital signatures below indicate that I (we) have knowingly and voluntarily waived the protection of state, federal and common law right to privacy laws for the limited purpose of providing address information to Out The Door Rent To Own. * I Agree READ STATEMENT BEFORE SIGNING. Name Date I certify that the information supposed by me on this form is true and correct. I authorize verification of the truthfulness of all information contained herein, included contact with any person for firm listed above, and fully release all parties from any liability for any damage that may result. Any false statement made above be sufficient basis for rejection of this order. I have read and understand the statement printed on this form. If this order is rejected, I may request the reasons(s) for same by sending a self-addressed, stamped envelope requesting the reason(s) to the store manager. * I Agree reCAPTCHA Submit
