Platinum Rental Rent To Own Application PO Box 606Cunningham KY 42035 Phone: 270-642-2202 Fax: 270-942-1142 https://platinumrentals.net/ Rent To Own Application Step 1 of 7 14% Timing(Required) Standard Urgent/Within 24 Hours Length Of Contract(Required) 36 Months 48 Months 60 Months Applicant InformationName(Required) First Last Social Security Number Choose Your Date Of Birth(Required) MM slash DD slash YYYY D. L. or ID Number(Required) Primary Phone(Required)Alt PhoneEmail(Required) Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required) Delivery Address (If different from mailing address) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County Co-Applicant InformationName First Last Social Security Number Choose Your Date Of Birth MM slash DD slash YYYY D. L. or ID Number Primary PhoneAlt PhoneEmail Land InformationAddress Of Building(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property Ownership Own Rent Indian Reservation If Applicable ~ Landlord's Name If Applicable ~ Landlord's Phone Employment InformationEmployment Information ~ Employer Employer Phone Building InformationBuilding Info New Used Model(Required) Size(Required) Inventory Number Roof Color(Required) Side Color(Required) Trim Color(Required) Building Price(Required) Option Cost(Required) Total Building Price (excluding taxes)(Required) Building Payment (excluding taxes)(Required) Taxes(Required) Total Payment (including taxes)(Required) Monthly Payment Made By Customer(Required) Down Payment(Required) Total Payment Made By Customer(Required) Monthly Payment Due Date (1-28)(Required) Method Of Payment(Required) Approval Code Check Number SignaturesAll sales orders are not complete until approved by the Corporate office. Merchant and its agents are not responsible for ground conditions, permits, setbacks, restrictions, or covenants that may affect, limit, or prohibit the placement of the Property at Consumer's desired location. Merchant is not responsible for yard or driveway damage. CANCELLATION/CHANGE ORDER POLICY: $100.00 minimum cancellation/change order fee, plus expenses as explained in Purchase Agreement. ALL CHECKS ARE SUBJECT TO ACH PROCESSING. ALL BUILDING SIZES ARE APPROXIMATE AND MEASURED FROM EAVE TO EAVE. I have read and agree to the terms and conditions explained above and in the Purchase Agreement:Sign Here(Required)By signing below, I (we) certify the information supplied by me on this form is true and correct and hereby authorize the release of any information, deemed necessary by lessor, relating to employment, income, and existing or prior leases. I (we) authorize lessor to use numbers/e-mails listed when making contact about account. Any false statement can be sufficient basis for rejection of this order. I (we) have read and understand this statement. I understand my credit will not be pulled to qualify for this rent to own agreement.Applicant Signature(Required)Date(Required) MM slash DD slash YYYY Co-Applicant SignatureDate MM slash DD slash YYYY Manufacturer InfoManufacturer(Required) Dealer Name(Required) Dealer Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Manufacturer Phone Number(Required)Salesman Name(Required)