1 Start 2 Complete
Customer Information
Full Name
Date of Birth
Social Security Number
Driver’s License no
State
Exp Date
Spouse/Roommate Full Name
Date of Birth
Social Security Number
Driver’s License no
State
Exp Date
Co-Signer Full Name
Date of Birth
Social Security Number
Driver’s License no
State
Exp Date
Bank Name
Bank Location City/State
Account Types
Address
Address Line2
City
State
Zip-Code
Home Phone
Cell Phone
Spouse / Roommate Cell
Email Address
Email
Spouse / Roommate Email
Length of Time at Current Address
Landlord / Mortgage Company
Phone Number
Lease in whose name
Length of Lease
Monthly Payment
Address
Address Line2
City
State
Zip-Code
Landlord / Mortgage Company
Phone Number
Lease in whose name
Length of Lease
Monthly Payment
Auto Make /Model
Auto Year
Auto Color
License Plate No
State
Ownership
Financed Through
Phone
Payment Amount
Paid
State
Ownership
Financed Through
Phone
Payment Amount
Paid
Employment
Employer
Title Position
Type
Date of Hire
Hours / Shift
Employer Address
Take Home Pay
Date Paid
Supervisor
Phone
Employer
Title Position
Type
Date of Hire
Hours / Shift
Employer Address
Take Home Pay
Date Paid
Supervisor
Phone
What is the best Day, Date to make your payment?
References

PERSONAL REFERENCES Must complete ALL Information for the References and They can NOT Live Together

Parent - Relative
Address
City State Zip
Phone
Relationship
Friend - Relative
Address
City State Zip
Phone
Relationship
Friend - Relative
Address
City State Zip
Phone
Relationship
Friend - Relative
Address
City State Zip
Phone
Relationship
Release

Release of Address and Employment Information to U Can Rent, Inc dba Family Home Furniture:


My (our) signature below this paragraph indicates that I (we) consent to the release of information concerning my (our) address or location to Family Home Furniture. This release will allow the disclosure to Family Home Furniture of information regarding me (us) that is currently in the possession of any agency or department of any state government, the United States of America, any reference given, or my (our) present or past landlord(s) or employer(s). I (we) know that there are certain state and federal laws which protect my (our) right to privacy by restricting access to information held by certain third parties. My (our) 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 Family Home Furniture. I agree to allow Family Home Furniture to contact me for any purpose necessary via voice, voicemail, text, and email, and that Family Home Furniture may utilize auto-dialer systems and prerecorded calls to contact me on my cell phone or at home or any phone numbers I provide on this form and subsequently provide to Family Home Furniture. I am applying for rental purchase and am over eighteen (18) years of age.
(Entering your digital signature below is a legal release of the above information)

Renter's Signature
Co-Renter's Signature

Please Read This Carefully!

I certify that the information supplied by me on this form is accurate to the best of my knowledge. I authorize verification of the truthfulness of all information contained herein, including contact with any person or firm listed above and agree to release all parties from any liability or damage that my result. I understand that any false statement made above may result in Family Home Furniture deciding not to rent to me at this time. IF YOU DEFAULT ON YOUR RENTAL AGREEMENT WITH U Can Rent, Inc dba FAMILY HOME FURNITURE, YOU AGREE TO ALLOW FAMILY HOME FURNITURE TO CONTACT YOUR REFERENCES ABOUT YOUR ACCOUNT. I/WE PERMIT FAMILY HOME FURNITURE TO CALL ME/US AT MY/OUR JOB AND HOME ABOUT MY/OUR ACCOUNTS.
(Entering your digital signature below is a legal release of the above information)

Renter's Signature
Date
Co-Renter's Signature
Date
Extra
How did you hear about us?
Have you ever leased/rental from another furniture company?
Furniture Company / Rental

Please check any item(s) you may have an interest in later: