RK's Rent to Own Application

Please select item of interest:
Furniture Appliances Electronics Computer

PERSONAL INFORMATION

Name:    Birthdate:
Soc Sec # : Drv Lic # :
Address:
City/State/Zip:
How Long? :     Home Phone # :
Current Landoard:    Address:
City/State/Zip:           Landlord's Phone # :
Residence Type: Own Rent
     Apt Home   Other
Utilities In Whose Name:
Your Cell or Pager Number# :
Monthly House or Rent Payment:
Lease In Whose Name:
Anyone Else on Lease? If Yes, Please Explain:
Email Address:
Previous Address (If less than 6 mo. at current address) :
City/State/Zip:
How Long? :
Previous Landlord: Previous LL Address:
City/State/Zip:       Previous LL Phone# :

VEHICLE INFORMATION

Auto Year: Make: Model: Color: Plate # :
Lien Holder:
Owned By:    Phone# :
Acct# :    Payment Amount:
How Often Payment Due
Comprehensive Insurance Yes No
Insurance Co. Name
Insurance Co. Phone# :     Policy# :
Co-Signer Name:
Co-Signer Phone# :

INCOME SOURCE

Employer:
Address:
City/State/Zip:
Phone # : Job Title:
Supervisor:
Dept: Shift:
Hire Date: Pay Day:
Take Home Pay:
Pay Frequency: Wkly Bi-Wkly Monthly Bi-Monthly
Working: FT PT Not At All
Addt'l Income:          Source: ADC SSI Disability Child Support Other
Spouse or Roomate: Relationship: Soc Sec # :
Cell or Pager # : Email Address: Employer:
Address:      City/State/Zip:
Phone # :

REFERENCES

Name (closest relative):
Relationship: Phone # :
Address: City/State/Zip:
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Name (closest relative):
Relationship: Phone # :
Address: City/State/Zip:
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Name (closest relative):
Relationship: Phone # :
Address: City/State/Zip:
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OTHER

How did you hear about us?: Ever rented from one of our other locations? Which one?:
Ever rented from another rental company? Which ones?:
Please Bring with You:
Driver's License, Social Security Card, Vehicle Registration/Title, Pay Check Stub/W-2, Phone Bill,
Utility Bill and Insurance Card.
Failure to provide these items will result in rejection of your rental privileges.

I(we) promise that the information I(we) have provided is correct. I(we) authorize complete verification of all information that I(we) have provided. You may contact any person(s) or company(s) listed above and I(we) fully release all parties from liability for any damage that may result. My(our) signature(s) below indicate that for the purpose of verification, I(we) have voluntarily waived the protection of all rights to privacy laws. I(we) also allow the release of my(our) address and telephone numbers to RK's RTO by any person(s), parties, companies or government agencies for up to 36 months form the date of this application. This form is an application to rent and may be rejected if I(we) fail to qualify or if any information above is found to be false.
With my(our) submission below, I(we) verify that I(we) have read and understand the above paragraph.