Customer Application

Please take a few minutes to complete this application for rental or stop into the showroom today. If you need any assistance completing this form, call one of our associates. Visit the Locations or Contact page for the telephone number of your closest store location.

Personal Information

First Name Last Name Date of Birth

Maiden Name (if applicable) How long at current address?

Street Address

City State Zip Code

Home Phone Number How is Phone Listed?

Check all that apply

Mobile Phone Pager

Email Address

Name of Apartments(or Landlord/ Mortgage Holder)

Landlord Phone Number

Previous Address

Street Address How long at this address?

City State Zip Code

Automobile Information

Drivers License # Make of Car

Model of Car Color of Car

Primary Renter Employment Information

Where Employed Phone Number

Company Address

Position Department Contact # Time w/ Company Payday

Supervisor's Name Your Social Security #

Spouse or Roomate Information

Name Maiden Name Phone no.

Where Employed Phone no.

Company Address

Position Department Contact # Time w/ Company Payday

Supervisor's Name Social Security #

Reference Information

Closest Relative's Name Relationship

Address Phone no.

Where Employed

Relative's Name Relationship

Address Phone no.

Where Employed

Reference #1 Name Relationship

Address Phone no.

Where Employed

Reference #2 Name Relationship

Address Phone no.

Where Employed

Tell us what you are interested in:

Which location should contact you about your application: Reading Allentown Harrisburg York