Rent-A-Center Securities Settlement - Nominee Contact Information

Nominee - Contact Information

Contact Information:

Business/Entity Name:*

First Name:*

Middle Initial:

Last Name:*

Country:*

Address 1:*

Address 2:

Address 3:

Address 4:

Address 5:

City:*

State:*

Province:*

ZIP Code:*

Postal Code:*

Phone Number:*

Email Address:*

Certification:

Capacity of Person Signing Form:*

Under penalty of perjury, I hereby certify that the foregoing information supplied by me is true, correct and complete to the best of my knowledge.*