VISIT CUCKOO RENTAL - DIAMOND BAR

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Home
Water Purifiers
Air Purifiers
Massage Chairs
Bidets
Beauty Devices
Pet Care
Apply Application

Rental /Purchase Application

2825 S Diamond Bar Blvd, DiamondBar, CA 91765

Sale Representative Information

Code:100956 Name:Jamie Wu Phone:(213)292-4444

Full Legal Name

Date Of Birth

SSN OR TIN

Primary Phone

Secondary Phone

Current Address

Room or Apt #

City

State

Zip Code

Provide your email address*

Installation Details

Same as Customer Information

Other Installation Address

Other Installation Address

Billing Address

Room or Apt #

City

State

Zip Code

Credit Card

Visa

Master Card

Amex

Discover

Please select payment date

10 th

15 th

Cardholder's Name

Credit Card Number

Expiration Date(MM/YY)

Security Code (cvv)

ACH INFORMATION

Checking Account

Savings Account

Please select payment date

10 th

15 th

Name on Account

Bank Name

Account Number

Routing Number

Showroom

2825 S Diamond Bar Blvd, DiamondBar, CA 91765

Jamie Wu - Phone:(213)292-4444

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