PRIMARY RENTER
Name:
Date of Birth:
Soc Sec No:
Cell Phone:
Email Address:
CO-RENTER
Name:
Date of Birth:
Soc Sec No:
Cell Phone:
Email Address:
RESIDENCE INFORMATION
Address:
City:
State:
Zip:
How Long:
Home Phone:
Landlord/Mortgage Company:
Number of People Living There:
Landlord Phone:
Rent or Home Payment:
Previous Address (if less than 1 year at current):
City:
State:
Zip:
How Long:
Landlord's Name and Phone:
RENTER'S EMPLOYMENT INFORMATION
Renter's Employer:
Address:
City:
State:
Zip:
How Long:
Work Shift/Schedule:
Occupation:
Supervisor:
Supervisor Phone:
Work Phone:
Salary:
Payday/Frequency:
Other Source of Income:
Other Source Amount:
Other Source Payday:
Other Source of Income 2:
Other Source Amount 2:
Other Source Payday 2:
CO-RENTER'S EMPLOYMENT INFORMATION
Co-Renter's Employer:
Address:
City:
State:
Zip:
How Long:
Work Shift/Schedule:
Occupation:
Supervisor:
Supervisor Phone:
Work Phone:
Salary:
Payday/Frequency:
Other Source of Income:
Other Source Amount:
Other Source Payday:
Other Source of Income 2:
Other Source Amount 2:
Other Source Payday 2:
VEHICLE INFORMATION
Renter's Auto Make & Model:
Year:
License Plate Number:
Driver's License Number:
Co-Renter's Auto Make & Model:
Year:
License Plate Number:
Driver's License Number:
REFERENCES
Closest Relative:
Relationship:
Address:
Phone Number:

Closest Relative 2:
Relationship:
Address:
Phone Number:

Relative:
Relationship:
Address:
Phone Number:

Relative:
Relationship:
Address:
Phone Number:

Friend:
Relationship:
Address:
Phone Number:

Friend:
Relationship:
Address:
Phone Number:
REFERENCES
Were you referred by anyone?
if yes, by whom:
Have you ever done business with a rent-to-own store?
if yes, with whom:
CHOOSE STORE
Which store would you like to do business with?
Your signature (name) below gives Homesource Rentals Permission to verify and discuss all account information given with everyone listed abo ve for the duration of the rental agreement. We will also use your ssn to obtain a tele-track report.
Renter's Signature/Name:
Co-Renter's Signature/Name: