Amigo Rent To Own - 956-519-5250

Customer Information

Name Date of Birth Sex Social Security #

Driver's License # Address Apartment

City State Zip Code How Long?

Residence Utilities in Whose Name Rent Amount

Phone Number Name of Phone's Owner Is this a home phone?

Previous Address (If less than 2 years)

City State Zip Code From To

Name of Current Land Lord Address

City State Zip Code Phone Number

Auto Make Model

License Plate # State Financed Through

Job Title Employer Address

City State Zip Code Hire Date

Position Supervisor Phone Extension

Comments

Working Paid Take Home Pay

Day of Week Paid Additional Income Source

Household Information

Name of Other Adult in Household Relationship

Social Security # Date of Birth Driver's License #

Job Title Employer Address

City State Zip Code Hire Date

Position Supervisor Phone Extension

Working Paid Take Home Pay

Day of Week Paid Additional Income Source

Personal References - We Need a minimum of four and two must be relatives

Reference 1

Name Relationship

Address City State Zip Code

Reference 2

Name Relationship

Address City State Zip Code

Reference 3

Name Relationship

Address City State Zip Code

Reference 4

Name Relationship

Address City State Zip Code

Have You Ever Rented From Another Rental Company?

Name of Other Rental Company Year

Relapse of information to amigo rent to own

The information I have provided on the form is correct. I authorize confirmation of all information that I have provided. You may contact any person or company that I have listed above and I fully release all parties form all liability for any damage that may result. My (our) signature(s) below indicates that for purpose of confirmation, I (we) have voluntarily waived the protection of all right to privacy laws. This order may be rejected if any information above is found to be false.

I AM APPLYING FOR RENTAL AND I AM OVER EIGHTEEN (18) YEARS OF AGE.

Name of Renter 1

Name of Renter 2

How Did You Hear of Amigo Rent To Own?