Personal Information

Please do not fill in this information until you have contacted us and you have been instructed to fill it out.

Fill in your credit card information. This information is so we can set your card up to auto pay every month.

First name

Last name

Phone

Street Address. Place where the washer & dryer will be delivered to.

City & State

Zip Code

Birthday

Month

Day

Year

Card Number

Address that is on the card:

City & State

Zip Code

Expiration date

CCV Number (3 digit)

Credit/ Debt

Credit

Debit

Employer

Employer Address

Emplyer Phone

Position Held

How long have you worked there?

Drivers license number and state it is from.

Special instructions:

1. Lease of Equipment

Title to the Equipment shall at all times remain with Lessor. This Agreement is a true lease and not a sale or financing arrangement.

2. Term

The lease term shall begin on the Effective Date and continue for a minimum of 4 months (“Term”), unless terminated earlier as provided herein.

Signature

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Now that you have filled out the form. Ask the delivery driver for your special code.