Address/Unit: _____________________________________________Rent:___________________  Date: ___________________

PERSONAL

Last Name:________________________________________  First Name:________________________  Middle Initial:__________
Birth Date:___________________________  Driver’s License Number:______________________________State:_____________  
SSN#:_______________________________Telephone Number_____________________________________________________

Additional Occupants (Please list below each individual and relationship, including children):
__________________________________________________________________________________________
__________________________________________________________________________________________

  •       Do you agree to pay your rent on time: Yes / No.  
  •       The late fees are $50 after 5 days and an additional $25 after 15 days.  
    Are you willing to accept these late fees in the unlikely event that you are late with your rent: Yes / No
  •       Do you agree to have your wages garnisheed if you get behind on rent: Yes / No
  •       Late-night parties and loud music are prohibited.  Do you agree to comply with this: Yes / No
  •       Waterbeds are prohibited!  Do you agree to comply with this: Yes / No
  •       Do you smoke indoors: Yes / No – If yes, add $10/month to the rent.
  •       Base rent allows for 1 occupant per bedroom.  Each additional occupant is $5 per month.
  •       Drug use and trafficking will not be tolerated!  
    If you are suspected of either, the police will be notified and you agree to be removed from the property: Yes / No
  •       Do you have a pet: Yes / No – If yes, please see the additional rent and deposit requirements below.
    Dogs under 40 lbs – Add $10/month rent and $250 non-refundable deposit.
   (Pits/Rotts/Pincers/Shepards etc. are prohibited)
   Cat (max of 2) – Add $5/month rent per cat and $250 non-refundable deposit.  (Must be spayed/neutered)
  •       Have you ever been convicted of a crime: Yes / No - If yes, please explain on the back.  
  •       Do you grant us permission to perform a police background check: Yes / No
  •       Have you ever broken a lease or refused to pay rent: Yes / No – If yes, please explain on the back.  
  •       Have you ever filed for bankruptcy or been taken to court by a landlord: Yes / No – If yes, please explain on the back.

RESIDENCE HISTORY

Current address:________________________________________  City:_______________________  State:_____  Zip:__________

How long:___________Do you currently: Rent / Own  What is your current monthly rent/mortgage payment:$____________________
Phone:____________________________________________  Mobile Phone:___________________________________________
Email:____________________________________________________________________________________________________
Name/Address/Phone of Current Landlord/Mortgage Lender:____________________________________________________
_________________________________________________________________________________________________________
Reason for moving:__________________________________________________________________________________________
Are your payments current: Yes / No  How many late payments have you had:____ Monthly payments $________________________

Previous address:_______________________________________  City:_______________________  State:_____  Zip:___________
How long:________________  Reason for moving:__________________________________________________________________
Name/Address/Phone of Previous Landlord/Mortgage Lender:____________________________________________________
__________________________________________________________________________________________________________
Was your full security deposit returned: Yes / No  How many late payments did you have:_____  Monthly payment:$________________

PAYMENT ASSISTANCE INFORMATION

In the event you would be unable to make a rent payment due to an emergency/vacation/unforeseen event, is there a relative, friend, or
agency that would be willing to assist you with rent payments?

Name/Address/Phone of emergency contact #1:_________________________________________________________________
__________________________________________________________________________________________________________
Relationship:______________________________  Phone:____________________________  Alt. Phone:______________________

Name/Address/Phone of emergency contact #2:____________________________________________________________________
__________________________________________________________________________________________________________
Relationship:______________________________  Phone:____________________________  Alt. Phone:______________________