Customer Information

Name:

Address:

Phone:

Email:

Store Information

Store Name:

Address:

Phone:

Item Description	SKU/Code	Quantity	Unit Price	Total

Total Purchase Price:

Down Payment:

Remaining Balance:

Number of Payments:

Payment Amount per Installment:

Due Dates:

Final Payment Due By:

The layaway agreement is valid for the term specified above, beginning from the date signed.
All payments must be made on or before the due dates listed.
If the final balance is not paid before the end of the layaway term, the merchandise may be returned to stock and any payments may be subject to store policy.
Customer may cancel this layaway at any time, subject to the store’s cancellation and refund policy.
Merchandise will only be released to the customer upon full payment of the total purchase price.
Other terms and conditions may apply as per store policy.

Customer Signature: Date:

Store Representative: Date: