MY STORE: Select your location

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Preferred Store

Store

Renter Information

Renters First Name *

Renters Last Name *

Cell Phone *

Email Address *

Sex *

Birth Date *

Social Sec # *

Drivers License Number

Home Phone *

Street Address *

City *

State *

Zip *

Mailing Address

Mailing City

Mailing State

Mailing Zip

Renter Employer/Income

Renters Employer/Source of Income *

Address

Phone *

Job Title *

Take Home pay *

Take home pay Amount

Length of Employment *

Pay Day *

Co-Renter Information

Co-Renters First Name

Co-Renters Last Name

Sex

Birth Date

Social Sec #

Drivers License Number

Employer/Source of Income

Take home pay Amount

Personal References

Name *

Phone *

Relationship

Name *

Phone *

Relationship

Name *

Phone *

Relationship

RELEASE OF INFORMATION TO Pay-Less Furniture And Appliances: (PLEASE READ BEFORE SIGNING)

The Information I(we) have provided on this form is correct. I authorize confirmation of all information that I(we) have provided. Pay-Less Furniture And Appliances may contact any person or company that is listed above, and I(we) fully release all parties from all liability from any damage that may result. My(our) Signature(s) below indicate that, for the purpose of confirmation, I(we) have voluntarily waived the protection of all rights to privacy laws. I also agree to accept messages from Pay-Less Furniture And Appliances regarding special sales or product offers via US mail, voice, email or text, and understand that I may opt-out at any time. This order may be rejected if any information provided above is found to be false.

FOR RENTER
I am applying for rental, and am over 18 years of age.

FOR CO-RENTER
I am applying for rental, and am over 18 years of age.

Please Respond to the Following Question and Prove You're A Human