RENT TO OWN AGREEMENT

Secure Online Form

To Submit Application
All items marked with an asterisk ( * ) are required items.
Unknown, Same As..., Not Applicable, etc., may be used when appropriate.
ALL CONTRACTS SUBJECT TO A CREDIT CHECK.

TERMS AND CONDITIONS
 CLICK HERE.
* I HAVE READ AND  AGREE
THE TERMS AND CONDITIONS OF THIS CONTRACT.

PERSONAL INFORMATION
   
* Your Name (last/first/middle):   
* Social Security Number:   
* Street Address:   
* City/:   
* State  
* Zip  
* Home Telephone (with area code):    
 E-Mail Address:    
   

Lessee's Employer:
* Employer's Name:   
* Work Telephone (with area code):    
Dept.      
* How Long  
* Street Address:    
* City:   
* State  
* Zip  
   

SPOUSE:
 Spouse's Name (last/first/middle): 
 Street Address:  
 City/State/Zip Code:  
 Home Telephone (with area code):
 E-Mail Address:
   

Spouse's Employer:
   
 Employer's Name:   
 Work Telephone (with area code):  
 Dept.  
 How Long  
 Street Address:  
 City/State/Zip Code:  
   

NEAREST RELATIVE (not living with you):
   
* Relative's Name:  
* Street Address:  
* Telephone (with area code):  
   

STUDENT:
   
* Student's Name:  
* School:  
   

*SELECT CATEGORY:

*SELECT INSTRUMENT:

*Must Choose Either Yes or No. This protection is for all repairs, regular maintenance, and replacement for theft or fire. Click here for details.
   

$3.95 PER MONTH       $5.95 FOR SAXOPHONE

I desire Replacement and Maintenance Protection

 

Value Pack Accessories

 

 
   

*CHOOSE PAYMENT METHOD

 

I do/do not authorize CIC to bill my
debit/credit card for each monthly payment.



CREDIT/DEBIT CARD INFORMATION:

 

Card #:

Expires:

SUBMIT RENTAL PURCHASE AGREEMENT

To Submit Application: Press the "Submit" button when you are ready to send this agreement to Central Instrument Company. If you wish to delete all your responses, press the Reset button. Please press the "Submit" button only once.