Date: _______(1)__________

Application is hereby made to rent premises generally described as ______________________(2)___________________________ for a term of __(3)__ and ending the _(4)_ day of _____(5)______, 19_(6)_, for which monthly rental shall be $____(7)____, payable in advance, and for which a security deposit of $____(8)____ shall be due prior to occupancy of the above-described premises.

A deposit of $___(9)___ is made herewith on account of the first month's rent, with the understanding that if this application is accepted and the applicant fails to execute a lease before the beginning date specified above, or to pay the balance due as first month's rent, said payment will be forfeited as liquidated damages.

It is also understood that if this application is not accepted, or if the premises are not ready for occupancy by the applicant on the date specified above, said deposit shall be refunded to the applicant forthwith, upon applicant's request.

APPLICANT

Name: __________________________________(10)___________________________________

Present Address: ___________________(11)_____________________ How Long? ____(12)___

Previous Address: __________________(13)______________________ How Long? ___(14)___

Married: ____(15)____ Spouse's Name: ______________________(16)____________________

Children? _______(17)_______ How Many? _______(18)_______ Ages? ________(19)_______

Pets? _______(20)_______ What Kind? ________(21)_________ How Many? ______(22)_____

YOUR EMPLOYMENT

Employer: _______________________________(23)___________________________________

Employer Address: ________________________(24)___________________________________

Supervisor: ____________(25)______________ Bus. Phone: ____________(26)_____________

How Long on Present Job? __________(27)____________ Annual Income: ______(28)_______

SPOUSE'S EMPLOYMENT

Employer: _______________________________(29)___________________________________

Employer Address: ________________________(30)___________________________________

Supervisor: _____________(31)_____________ Bus. Phone: ____________(32)_____________

How Long on Present Job? ________(33)_________ Annual Income: ________(34)__________

REFERENCES

Bank: _________________(35)___________________ Phone: ___________(36)____________

Personal Reference: _________(37)_______________ Phone: ___________(38)____________

Credit Reference: ____________(39)______________ Phone: ____________(40)____________

Credit Reference: ____________(41)______________ Phone: ____________(42)____________

______________(43)_____________

The information provided herein may be used by the landlord or his agent to determine whether to accept this application. Upon written request within 30 days, the landlord or his agent will disclose to applicant in writing the nature and scope of any investigation landlord has requested, and will, if this application is refused, state in writing the reason for said refusal.

Accepted ________ Refused ________

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