RNR Tire Express - Get Approved Online

By completing this form, and providing your digital signature, you agree that all of the information is correct and authorize complete verification of all provided information prior to delivery.

Personal Information

Tell us about yourself and how to reach you.

Nearest Location *

Product of Interest *

Tires Wheels Tires & Wheels

About You

First Name *

Last Name *

Date of Birth *

Email *

Cell Phone *

Work Phone

Current Address

Street Address *

Apt / Unit

City *

State *

Zip Code *

How Long at Current Address? *

Landlord Name or Own Home *

Landlord Phone

Monthly Rent/Mortgage Payment *

Employment & Income

Tell us about your current employment.

Employer / Where You Work *

Work Location *

Employer Phone *

Job Title *

Shift / Hours *

How Long at Job? *

Income

Take Home Pay (Estimate) *

How Often Do You Get Paid? *

What Days Do You Get Paid? *

Other Income (Optional)

Source

Amount

How Often?

Vehicle Information

Tell us about the vehicle getting tires/wheels.

Vehicle Year *

Vehicle Make *

Vehicle Model *

Vehicle Color *

License Plate / Tag # *

Owner Name(s) on Registration *

Vehicle Financing

Purchase Date (Estimated) *

Finance Company or Car Lot

Vehicle Payment Amount

Finance Company Phone

Does the Loan Have a Co-Signer? *

No Yes

Have You Done Lease/Rent-to-Own Before? *

No Yes

Personal References

Please provide 4 references at different addresses. Only 1 may share your address.

Important: Only 1 reference can share the same address as you. The other 3 must have different addresses from each other. Duplicate addresses may require additional references. You can provide address details by time of install.

Reference 1 — Close Relative

Full Name *

Relationship *

Cell Phone *

City & State

Street Address

Reference 2 — Family Member

Full Name *

Relationship *

Cell Phone *

City & State

Street Address

Reference 3 — Family or Close Friend

Full Name *

Relationship *

Cell Phone *

City & State

Street Address

Reference 4 — Family or Friend

Full Name *

Relationship *

Cell Phone *

City & State

Street Address

Review & Sign

Please read the agreement below and provide your signature.

Please verify you will have the following documents on the day of install:
• Valid Driver's License
• Valid Vehicle Registration
• Pay Stub (Proof of Income)
• Utility Bill (Proof of Address)
• Debit/Credit Card for Automatic Payments

General Release

PLEASE READ THIS STATEMENT BEFORE SIGNING
I promise that the information I have provided on this form is correct. I authorize complete verification of all information I have provided. You may contact any person or company listed above and I fully release all parties from liability for any damage that may result. My (our) signature(s) indicates that for purposes of verification, I (we) have voluntarily waived the protection of all rights to privacy laws. This order may be rejected if any information provided is found to be false. By providing your contact information, you consent to receive emails from RNR Midwest which may include emails related to payments or advertisements, receive texts from Rent One which may include texts related to payments or advertisements, and receive telephone calls from RNR Midwest that may include prerecorded messages on behalf of RNR Midwest related to payments or advertisements.

Release of Information to Rent One
By your signature below, whether one or more applicants, you also agree to allow RNR Midwest employees to contact the references listed above and your employer(s) to verify your information and to assist RNR Midwest in its collection efforts if you fail to renew the rental agreement or return the merchandise to RNR Midwest on time. This waiver is valid until you revoke it by notifying RNR Midwest in writing by certified mail. I have read and understand these statements.

Electronic Signature Consent
This Electronic Signature Consent ("Consent") sets forth the terms of my consent to sign documents electronically through the RNR Midwest Signature System ("System").

I may decline to electronically sign any document. I may contact RNR Midwest and request a paper copy of any document signed electronically through the System.

I understand that (i) electronically signing any document(s) legally binds me in the same manner as if I had signed in a non-electronic form, and (ii) the electronically stored copy of my signature is considered to be the accurate and complete record, legally enforceable in any proceedings to the same extent as if such documents were originally generated in printed form. I agree not to contest the admissibility or enforceability of RNR Midwest's electronically stored copy of this Consent and any other documents. By using the System to electronically sign and submit any document, I agree to the terms and conditions of this Consent.

I have read and understand the statements above. *

Renter Signature

Renter's Signature (Type Full Name) *

Today's Date *

NOTE: All applications must be verified by store manager before rental application can be approved.

Preferred Install (Optional)

Preferred Install Date

Preferred Install Time

Personal Information

Employment & Income

Vehicle Information

Personal References

Review & Sign

Application Submitted!