customer-orderform

Contact Information

Step 1

First Name * Last Name * Email * Date of Birth * Phone * Address * Apt/Unit City * State * Zip Code *

Residency

Step 2

Residency *

Time at Address *

Monthly Payment * Landlord / Contact * Landlord Phone *

Income Information

Step 3

Employer / Income Source * Employer Phone * How Long There? *

Personal References

Step 4

Ref 1 Name * Ref 1 Phone * Ref 1 Relationship *

Ref 2 Name * Ref 2 Phone * Ref 2 Relationship *

Ref 3 Name * Ref 3 Phone * Ref 3 Relationship *

Products of Interest

Step 5

Describe here: *

Preferred Store Location

Step 6

Select Store *

Agreement

Final Step

I agree that Continental Home Center may verify the accuracy of this application, including contacting my work, landlord/housing provider, and references via phone or text.