Customer Order Form

Customer's Information

Full Name *

Email *

Phone *

Date of birth *

Social Security Number

Sex *

Skip to "Address" if you do not have a Co-Applicant

Co-Applicant

Co-Applicant Phone Number

Co-Applicant Date Of Birth

Co-Applicant Sex

Address *

Apt/Floor

City *

State *

Postal code *

Residence Is *

Residence Type *

Current Landlord *

Put N/A if you Own your home

Landlord's Phone Number *

Put N/A if you Own your home

Landlord's Address *

Put N/A if you Own your home

Landlord's City,State &Zipcode *

Put N/A if you Own your home

Monthly Rent Amount *

Put N/A if you Own your home

How long have you lived here? *

Put N/A if you Own your home

Lease Term End Date *

Put N/A if you Own your home

Skip to "Employment Information" if you've lived at your current address for over 6months

Previous Address (If less than 6 months at current address)

Previous Landlord

Previous Landlord Phone Number

Previous Landlord Address

Employment Information

Current Employer *

Employer Address *

Job Title *

Hire Date *

Shift *

Department *

Supervisor *

Supervisor Phone Number *

Work Schedule *

Paid *

Day or Dates Paid *

Take Home Pay/Next Pay Day *

Additional Income *

Source of Additional Income *

Skip to "Personal References" if you do not have a Co-Applicant

Co-Applicant's Employer

Co-Applicant's Employer Address

Co-Applicant's Job Title

Co-Applicant's Hire Date

Co-Applicant's Shift

Co-Applicant's Department

Co-Applicant's Supervisor

Co-Applicant's Supervisor's Phone Number

Co-Applicant's Work Schedule

Co-Applicant's Paid

Co-Applicant's Day or Dates Paid

Co-Applicant's Take Home Pay/Next Pay Day

Co-Applicant's Additional Income

Co-Applicant's Additional Income Source

Personal References- Family Members Preferred (Please Complete All Information)

Reference #1

Reference #1 Full Name *

Reference #1 Phone Number *

Reference #1 Full Address *

Reference #1 Relationship *

Reference #2

Reference #2 Full Name *

Reference #2 Phone Number *

Reference #2 Full Address *

Reference #2 Relationship *

Reference #3

Reference #3 Full Name *

Reference #3 Full Address *

Reference #3 Phone Number *

Reference #3 Relationship *

Reference #4

Reference #4 Full Name *

Reference #4 Phone Number *

Reference #4 Full Address *

Reference #4 Relationship *

Disclosure For Order

RELEASE OF INFORMATION TO PREMIER- Please Read Statement Before Signing

You agree to allow us or our agents and assigns, including debt collectors, to contact you for business purposes including application qualification notification, solicitation, marketing and collections via multiple communication channels including, email, telephone, or text message, directly or by using a dialer, automatic telephone dialing system, interactive voice recognition system or artificial or prerecorded voice or message at any number you have given us or any number you give us in the future (whether home, cell or mobile service) even if you are charged for the call by your telephone service provider. You expressly agree to be contacted via such automated calls and communication methods. You do not have to agree to get marketing communications from us in order to rent products from us. You can opt out of getting marketing messages from us by notifying us of your intent to opt out.

Applicant Digital Signature *

Co-Applicant Digital Signature

Purchase Information

What Would You Like To Rent? *

How did you hear about us? *

Have You Purchased From Premier Before? *

If Yes, How Long Ago?

Have You Purchased From Other Rental Companies? *

If Yes, How Long Ago Did You Rent From Someone Else?

Please Provide Detailed Directions To Your Home

Directions To Your Home *