Fill out the form below and submit or download the PDF to fax, mail, email, or bring into the store.
Full Name
Address
City / State
Zip Code
Phone Number
Cell Phone
Married or Single? MarriedSingle
Drivers License Number
Bank Name & Address
Employer
How long have your worked here?
Home: OwnRent
Landlord (if applicable)
Landlord's Phone Number
Receive invoices by email? YesNo
Email Address
Name of nearest relative not living with you
Relative's Phone Number
Relationship
Personal Guaranteed Payment of charges incurred by the applicant: I agree to payment of monthly account due by the 5th of the month following the month of purchase. I agree to pay a late fee of 1.5% per month until paid in full, if not paid by the 10th. I agree to pay reasonable attorney fees and all collection expense if not paid by these terms. All accounts will be put on credit hold after 60 days and after 90 days a lien will be filed on the property where the material was delivered. Any payment on account by credit card is subject to a 3% convenience fee.
I agree to all terms above.
Applicant
Co-Applicant
Date
Delivery / 911 Address
I, the undersigned buyer or representative thereof, certify that the above described Delivery Address and information is true and correct.
Buyer's Signature
Delivery Directions
