PERSONAL INFORMATION |
|
DATE:______________ |
Interviewed By __________________________ |
Name of Applicant ________________________________ Telephone _______________________ |
|
Social Sec. No _____________________________ Driver's License No. ________________________________ |
|
Present Address __________________________________________________________ |
|
City _______________________ State ____________ Zip ______________ |
|
Prior Address ____________________________________________________________ |
|
City _______________________ State ____________ Zip ______________ |
|
| How long have you lived at preset address? _______________ How long have you lived at prior address? ____________ |
|
Name of Landlord _____________________ Telephone ______________________ |
|
Prior Landlord _______________________ Telephone ______________________ |
|
How many will be living in this unit Adults _________ Children ___________ |
|
Employer ___________________________________________ Position ______________________________ |
|
How long? __________________________ Income ________________ Telephone ______________________ |
|
SPOUSE INFORMATION |
| Name ________________________________________ |
| Social Sec. No. ____________________ Driver's License No. _______________________ |
| Employer ___________________________________ Position _______________________________ |
| How long? __________________________________ Telephone _____________________________ |
BANK INFORMATION |
| Bank Name _______________________________________ Telephone ____________________________ |
| Address _________________________________________________________________ |
| Checking Account No. _______________________ Savings Account No. ___________________________ |
PERSONAL REFERENCES |
||
Name |
Relationship |
Telephone |
_____________________________ _____________________________ |
_____________________________ _____________________________ |
_____________________________ _____________________________ |
OTHER INFORMATION |
Number of vehicles (including company cars) ____________________________________________________ |
| HAVE YOU EVER Filed for bankruptcy Yes No If yes, when? ______________________________ Been served an eviction notice or been asked to vacate a property you were renting? Yes No Willfully or intentionally refused to pay rent when due? Yes No If yes, when? ______________________________ |
| How were you referred to us? Newspaper (name) __________________ Internet Other _____________________ Rental Unit applied for ______________________________________ Commencement date _________________________ Term ____________________ Rent/Month ___________________ |
DISCLOSURES |
|
RADON GAS - Notice to Prospective Tenant Radon is a naturally occurring radioactive gas that, when it has accumulated in a building in sufficient quantities, may present health risks to persons who are exposed to it over time. Levels of radon that exceed federal and state guidelines have been found in buildings in this state. Additional information regarding radon and radon testing ma be obtained form your county public health unit. LEAD PAINT- Every purchaser of any interest in residential real property on which a residential dwelling was built prior to 1978 is notified that such property may present exposure to lead from lead-based paint that may place young children at risk of developing lead poisoning. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities, reduced intelligence quotient, behavioral problems and impaired memory. Lead poisoning also poses a particular risk to pregnant women. The seller of any interest in residential real estate is required to provide the buyer with any information on lead-based paint hazards from risk assessments or inspection in the seller's possession and notify the buyer of any known lead-based paint hazards. A risk assessment or inspection for possible lead-based paint hazards is recommended prior to purchase. |
ACKNOWLEDGEMENT |
I/We, the undersigned, understand that _________________________ is the leasing agent and representative for the owner/landlord and that the leasing agent's fees will be paid by the owner/landlord. The undersigned acknowledge that this written notice was received prior to the undersigned receiving a lease agreement. I/We declare the foregoing information is true and correct and I/We hereby authorize you to conduct an employment and credit check and to verify our references. |
_____________________________________________ ____________________________________________ Applicant's Signature Date Co-Applicant's Signature Date |