Online Application Form

Preferred Store

Store

Renter Information

Renters First Name *

Renters Last Name *

Cell Phone *

Email Address *

Drivers License Number *

Home Phone

Street Address *

City *

State *

Zip *

Renter Employer/Income

Renters Employer/Source of Income

Residence Information

Co-Renter Information

Co-Renters First Name

Co-Renters Last Name

Phone

Personal References

Name *

Phone *

Relationship *

Name *

Phone *

Relationship *

Name *

Phone *

Relationship *

RELEASE OF INFORMATION TO Express Rent To Own: (PLEASE READ BEFORE SIGNING)

The Information I(we) have provided on this form is correct. I authorize confirmation of all information that I(we) have provided. Express Rent To Own may contact any person or company that is listed

FOR RENTER
I am applying for rental, and am over 18 years of age.

FOR CO-RENTER
I am applying for rental, and am over 18 years of age.

Please Respond to the Following Question and Prove You're A Human

Disclaimer: *Receive up to $50 towards your weekly payments on any new agreement of $20 per week or more. Scratch off has no cash value. Some restrictions may apply. See store for details. Expires 5/31/25.