Triad Leasing Rent to Own Center

Social Security # (For customer ID / Account #)
Full Name:
Home Phone
Cell Phone
Address
City
State
Zip
Email Address:
Roomate / Spouse:
Roomate / Spouse Phone:
How long have you lived at your current address?
Driver's License Number
Driver's License State:

Current Employer:
Current Employer Phone Number:
Length at job:
Occupation/Title:
Employer Contact Person:
Roomate/Spouse Employment:
Roomate/Spouse Employment Phone Number:

Landlord Name:
Landlord Phone:
Address:
Months remaining on current lease:
If you have been at your current address less than 10 months, please list your previous landlord information
Year, Make, and Model of Car:
License Plate Number:

Permanent Contact (example: Parent or relative):
Relationship to You:
Permanent Contact Phone:
Permanent Contact Address:
Permanent Contact City:
Permanent Contact State:
Permanent Contact Zip:

Personal Reference #1 Full Name:
Personal Reference #1 Relationship to You:
Personal Reference #1 Phone Number:
Personal Reference #1 Address:
Personal Reference #1 City:
Personal Reference #1 State:
Personal Reference #1 Zip:

Personal Reference #2 Full Name:
Personal Reference #2 Relationship to You:
Personal Reference #2 Phone Number:
Personal Reference #2 Address:
Personal Reference #2 City:
Personal Reference #2 State:
Personal Reference #2 Zip:

Have you rented from us or any other rental company? If Yes, which one?
How did you hear about us? (TV, Phone Book, Drive By, Newspaper, Internet, Referral, Other)

I declare that the information listed above is true and correct. I authorize the Rent-To-Own Center, its agents and attorneys, to obtain and investigate information related to me from the persons, companies or others identified above. I also authorize the release of information related to me by persons, companies and others, whether identified above or not, to the Rent-To-Own Center, its agents and attorneys. I hereby consent to and understand that agents working on behalf of Rent-To-Own Center may contact the persons, companies and others identified above in order to obtain information concerning my current or past whereabouts, my current or former banking activity, my current or former employment and my current or former spouse. I understand that if I fail to return rental property when due it may result in the charge of amounts due to my credit or debit card account(s), using electronic processing information provided by me to Rent-To-Own Center. I authorize charges for merchandise not returned by my signature below. All charges for non-returns are final and a receipt will be mailed to the last address provided.