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Ecommerce Order Form

The document is a Customer Order Form that collects personal, employment, and automobile information from the customer. It includes a release of information statement that requires the customer to certify the accuracy of their provided information and consent to be contacted for account-related and marketing purposes. The form also emphasizes the customer's right to opt-out of automated calls and marketing communications.

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chambers8028
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7 views1 page

Ecommerce Order Form

The document is a Customer Order Form that collects personal, employment, and automobile information from the customer. It includes a release of information statement that requires the customer to certify the accuracy of their provided information and consent to be contacted for account-related and marketing purposes. The form also emphasizes the customer's right to opt-out of automated calls and marketing communications.

Uploaded by

chambers8028
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CUSTOMER ORDER FORM

All you need is:


Your Phone
Your Wallet
Your Keys/Vehicle

CUSTOMER INFORMATION
Full Name Nickname / Maiden Name SS# (Last 4) XXX-XX-

Address Apt. City/State Zip How Long? yr. mo.

Previous Address Apt. City/State Zip How Long? yr. mo.

Home Phone # Cell # Email

Driver License # (Last 4) State DOB Sex: M F Married / Single

Employer Position Hire Date

Work Address Work Phone # Supervisor

Take Home Pay $ Weekly / Bi-Weekly / Monthly Full / Part / Temp Next Payday

Rent/House Payment $ Paid To: Phone #

AUTOMOBILE INFORMATION
Year Make Model Color License / Tag #

Registered Owner(s) VIN#

Payment $ Due Date Purchase Date

Lienholder Phone # Account #

PERSONAL REFERENCES
1. Name Address Relationship Phone #

2. Name Address Relationship Phone #

3. Name Address Relationship Phone #

4. Name Address Relationship Phone #

5. Name Address Relationship Phone #

RELEASE OF INFORMATION Please Read The Following Statement Before Signing


You certify that the information you have provided on this Customer Order Form is true and correct. You understand that if any of the information
you provided is found to be false this order may be rejected. By signing below, you agree that we or our agents can contact you about your
account with us via email, telephone (including cell phones), or text messages at any email address or phone number you have given us, even if
you are charged for the call. You also agree that we can contact you with special offers and other marketing information with these methods. You
agree that we may use automatic dialing systems or pre-recorded messages. You certify that the number(s) you have given us are for phone(s)
that belong to you.
Consent to receive special offers and marketing information is not a condition of purchase/rental. You can cancel your consent to get automatic
dialing calls or pre-recorded messages by notifying us by any reasonable means, including written notice to Rent A Tire, L.P. at 2895 113th Street,
Grand Prairie, TX. 75054, by emailing us at [email protected], or calling us at (888) 505-8473. You also agree that, from time to time, we
may monitor telephone conversations between you and us to assure the quality of our customer service. You also agree to notify us promptly if
you change any of the phone numbers you have given us.
I hereby acknowledge that I have read and understand the statement above and certify that I am eighteen (18) years of age or older and I am able
to enter into any legally binding agreement.

Customer Signature Date

COF 09.03.2024

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