Contintental - Customer Order Form

Online Order Form


Customer Infomation Renters Full Name Date of Birth Email Address Drivers License # Street Address City State Zip Code Home Phone Cell Phone # Renters Employer Employer's Phone	Job Title Supervisor Take Home Pay How Often Paid? How Long There? Additional Income Source Income Amount How Often Paid? Auto Make? Auto Year Auto Color License Plate #	Landlord/Mortage Co. Name Phone Number Monthly Payment Years Lived There Name of Lease (if rented) Previous Address (if less than 3 years) Previous Landloards Name Phone Number Number of Years There? Monthly Payment

Co-Renters Information Co-Renters Name Date of Birth Drivers License #	Co-Renters Employer Phone Job Title Supervisor	Take Home Pay How Often Paid? How Long There?


Family References
Name	Address (Nearest Living Relative)	City	State	Zip Code	Home Phone	Relationship


Additional Information How did you hear about Continental Rental? TV Commercial Radio Commercial Yellow Page Ad Drove By	Have you ever rented from another rental company? Yes No (if yes) What rental company? (if yes) In what city?	What is your marital status? Single Married Divorced/Separated/Widowed
Product(s) interested in:


Choose which store your email will be sent to:

Please read statement:
I certify the information given by me on the form is true and correct. I authorize verification of the truthfulness of all information, including contact with any person or firm listed above, and fully release all parties from all liability for any damage that may result. Any false statement made above shall be sufficient basis for rejection of the order.

I have read and understand the above statement