Customer Infomation

Renters full name
Date of Birth
Email address
Drivers license Number
Street address
City
State
Zip code
Home phone
Cell phone #
Renters employeer
Phone
Job title
Supervisor
Take Home pay
How often paid?
How long there?
Additional income source
Income Amount
How often Paid?
Auto Make?
Year
Color
License Plate #
Landlord/Mortage Co.
Name
Phone Number
Monthly payment
Years lived there
Name of Lease (if Rented)
Previous Address(if less than 3 years)
Previous Landlords Name
Phone Number
Number of year there?
Monthly Payment
   

Co-Renters Infomation

Co-Renters name
Date of Birth
Drivers License Number
Co-Renters Employeer
Phone
Job Title
Supervisor
Take home pay
How often paid?
How long there?
 

Family References

Name Address
(Nearest Living Relative)		 City State Zip Code Home Phone Relationship
             

Additional Infomation

How did you hear about Continental Rental?
Have you ever rented from another rental company?
What rental company?
City?
What is your marital status?
Product(s) interested in    
     

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I certify the information given by me on the form is true and correct. I authorize verification of the truthfulness of all information, including contact with any person or firm listed above, and fully release all parties from all liability for any damage that may result. Any false statement made above shall be sufficient basis for rejection of the order.