Preferred Store

Store

Title *

First Name *

Last Name *

Address *

City *

State *

Zip *

How long have you lived at this address?

Email *

Birth Date *

Cell Phone *

Home Phone *

Workplace *

Work Phone *

How long have you worked at your current job?

Boss's Name

Landlord's Name

Landlord's Phone

Parent's Name

Parent's Phone

Address *

City

State

Zip Code

I Agree

I promise that the information I have provided on this rental order form is correct. I authorize Mike's Rent-to-Own to completely verify all of the information that I have provided. Mike's Rent-to-Own has my express authorization to contact by phone, text message, or social media any person, landlord, or employer listed on the rental form to discuss my account. This form is an application to rent and may be rejected if I fail to qualify or if any information if found to be false.

Personal References

Please submit at least two references. We may ask for a few more when you come into the store.

Item 1

Relative/Friend First Name *

Relative/Friend Last Name *

Relationship to you

Address

City

State

Zip Code

Cell Phone *

Work Phone

Item 2

Relative/Friend First Name *

Relative/Friend Last Name *

Relationship to you

Address

City

State

Zip Code

Cell Phone *

Work Phone

Item 3

Relative/Friend First Name *

Relative/Friend Last Name *

Relationship to you

Address

City

State

Zip Code

Cell Phone *

Work Phone

Item 4

Relative/Friend First Name *

Relative/Friend Last Name *

Relationship to you

Address

City

State

Zip Code

Cell Phone *

Work Phone

Optional Item

Relative/Friend First Name *

Relative/Friend Last Name *

Relationship to you

Address

City

State

Zip Code

Cell Phone *

Work Phone