Online Application Form

Preferred Store

Store

Renter Information

Renters First Name *

Renters Last Name *

Cell Phone *

Email Address *

Birth Date

Social Sec #

Drivers License Number

Street Address *

City *

State *

Zip *

Mailing Address

Mailing City

Mailing State

Mailing Zip

Have you rented before?

Renter Employer/Income

Renters Employer/Source of Income

Phone

Take Home pay

Length of Employment

Pay Day

Residence Information

Do you rent your residence?

Landlord Name

Phone

Time Lived at Residence

Co-Renter Information

Co-Renters First Name

Co-Renters Last Name

Phone

Birth Date

Social Sec #

Drivers License Number

Employer/Source of Income

Personal References

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

RELEASE OF INFORMATION TO Lebakkens Rent To Own: (PLEASE READ BEFORE SIGNING)

I understand that any of the above people or places of business may be called at any time for verification or any other reason deemed necessary. I understand that if any of the information above is found to be false, Lebakkens will have the right to demand return of its property without losing their rights to any outstanding debts due them. In addition, I will lose my legal claim concerning Lebakkens and could be criminally prosecuted under applicable local, state and federal laws.

FOR RENTER
I am applying for rental, and am over 18 years of age.

FOR CO-RENTER
I am applying for rental, and am over 18 years of age.

*Not valid with any other offer. Offer good for $65.00 off your first monthly rental payment and $65 is off the total rental purchase price. Some restrictions may apply. Valid through September 30, 2025. This is a rent-to-own agreement and no ownership rights are acquired until the total amount is paid or same as cash or early buyout option is executed. Example: $6.99 x 52 weeks = $363.48 plus tax and applicable fees. ©️2025 Lebakkens Rent to Own