Tel-A-Rent Credit Application

NOTE: IF YOU WOULD LIKE TO APPLY FOR A PAYDAY LOAN, PLEASE CLICK THE LINK ON THE RIGHT ABOVE

Please take a few minutes to fill this form out fully and completely so that it may be reviewed and verified for approval. Most applications are processed immediately, but please allow up to 24 hours for completion of the verification process. Once approved a representative will contact you at the phone or e-mail address listed on application. PLEASE NOTE: Although we are a rental company you are not obligated to keep the merchandise for the full term of the contract, however we have a mandatory 4 MONTH MINIMUM POLICY on ALL rentals, and any rentals for shorter than that period of time MUST be approved by management. Thank you for choosing Tel-A-Rent and we look forward to serving you for all your home furnishing needs.

I am interested in renting from
I am interested in renting	Furniture
	Appliances
	Electronics-Computers
	Whole Home/Corporate
	Mowers/Grills
	Custom Wheels
Primary First/Last Name
Address
City
State
Zip Code
Phone
Cell/Alternate Phone
Residence is
Time at Residence
Utilities in Whose Name
Drivers License #
State Issued
Sex	Male
Sex	Female
Birthday
Social Security #
Current Landlord or Mortgage Company
Landlord/Mortgage Address
Landlord Mortgage City,State,Zip
Landlord/Mortgage Phone #
Previous Address ( If Less Than 3 Months at Current Address)
Previous City,State,Zip
From Date-To When
Previous Landlord
Previous Landlord Address
Previous Landlord City,State,Zip
Previous Landlord Phone #
Auto-Year
Auto-Make
Auto-Model
Auto-Color
Auto Licence Plate #
Vehicle Is	Owned
Vehicle Is	Financed
Company (If Financed)
Finance Company Phone #
SOURCE OF INCOME	Empty
Job Title
Employer
Address
Employer City,State,Zip
Hire Date
Shift Hours
Department
Supervisor
Employer Phone #
Ext #
Work Status
Pay-Period
Day Of Week or Month Paid
Approximate Primary Renter Monthly Take Home Pay
Additional Monthly Income Amount
Source
SECONDARY/ADDITIONAL ADULT INFORMATION	Empty
Name of Other Adult in Household
Other Birthday
Other Maiden Name
Other Relationship To You
Other Social Security #
Other Employment Status
Job Title (If Applicable)
Other Employer
Other Employer Address
Other Employer City,State,Zip
Other Employer Phone # & Ext.
Other Hire Date
Other Shift Hours
Other Department
Other Employer Supervisor
Other Pay Period
Other Day Of Week or Month Paid
Other Approximate Take Home Pay
Other Additional Income
Source
PERSONAL REFERENCES	Empty
Name (Closest Relative) Address,City,State,Zip,Phone Number & Relationship to You
Name (Closest Relative) Address,City,State,Zip,Phone Number & Relationship to You
Name,Address,City,State,Zip,Phone Number & Relationship to You
Name,Address,City,State,Zip,Phone Number & Relationship to You
Name,Address,City,State,Zip,Phone Number & Relationship to You
Name,Address,City,State,Zip,Phone Number & Relationship to You
How did you hear about us?
How many miles from closest store?
Have you ever rented from Tel-A-Rent before?	Yes
Have you ever rented from Tel-A-Rent before?	No
If Yes, How long Ago?
Please list any other companies you have rented from
TEL-A-RENT RELEASE OF INFORMATION	Empty
I promise that all the information on this form is true and correct to the best of my knowledge. I authorize complete verification of all the information that I have provided. You may contact any person or company listed above and I fully release all parties from all liability for any damage that may result. My (our) electronic signature, and agreement indicates that for the sole purpose of verification. I (we) voluntarily waived the protection of all rights to privacy laws. I understand that this order may be rejected if any information provided above is found to be false. My (our) electronic signature also represents my (our) understanding, and agreement to your 4 month minimum policy on all agreements, and agree to abide by all terms and conditions.
Primary Renter Electronic Signature
Secondary Renter Electronic Signature
Today's Date

This web page is an ad and is an invitation for you to send us a payday loan or rental application, and not an offer to make you a rental or payday loan. We are based in Missouri and subject to the laws of the state. If you submit a rental or payday loan application to us and it is approved, we will contact you with further instructions.

1349 S Glenstone Avenue * Springfield, Missouri 65804 * 417-881-3533