RGM Rentals

New Application 1/6

First Name *

Middle Name

Last Name *

Social Security Number 999-99-9999

Driver's License Number *

Date of Birth * MM/DD/YYYY

Sales Person's Name (If you have one)

Dealer Company Name (If you have one)

* required fields

Mailling Address *

100 characters remaining

City *

State *

Zip Code *

County *

Email Address

Home Phone (Landline Only)

Cell Phone

RGM Rentals may send SMS

Yes No

* required fields

copy from mailing address

Physical Address *

100 characters remaining

City *

State *

Zip Code *

County *

At This Address Since * MM/YYYY

Own or Rent Storage Location *

Landlord's Name *

Landlord's Phone *

* required fields

Closest Relative *

Relationship *

Phone *

Friend/Relative *

Relationship *

Phone *

Friend/Relative

Relationship

Phone

Two References required, three for additional points. May not live in same household.

* required fields

Employment Status *

Do you have a checking account?

Yes No

Do you have a savings account?

Yes No

Do you wish to enroll in monthly AutoPay (auto-draft) for extra points?

Yes No

Include Limited Damage Waiver?
(Cost is 10% of monthly payment)

Yes No

* required fields

Add your spouse/other as a Co-Renter for extra points?*

Yes No

Cell Phone *

Employment Status *

* required fields