Name ________________________________ Home Phone ____________________

Soc. Sec. No. ____________ Work Phone __________ Driver's license ____________

Present Address ___________________________________________ How long at this address? _______ Rent $ ___________ Reason for Moving ______________________ ________________________ Owner/Manager ________________ Phone _________

Previous Address __________________________________________ How long at this address? _______ Rent $ ___________ Reason for Moving _______________________ _________________________ Owner/Manager _________________ Phone ________

Name and relationship of every person to live with you, even if only temporarily (include names and ages of minors): ________________________________________________

______________________________________________________________________

Any pets? ______ Describe ________________________________ Waterbed? ______

Occupation __________________ Employer _____________________ Phone ________

Duration of Employment _______ Supervisor ______________________ Phone _______

Previous Occupation _________________ Employer ________________ Phone _______

Duration _________ Supervisor _______________________________ Phone ________

Current Gross Income Per Month (before deductions) $ ___________________________

List sources of income (other than employment listed above ________________________ ______________________________________________________________________

Savings Acct.. _________ Branch ______________ Acct.. No. ______________________

Checking Acct. ________ Branch ______________ Acct.. No. _____________________

Major Credit Card __________ Acct. No. ________________________ Expires _______

Credit Reference ______________________ Acct. no. __________ Balance Owed _____

HAVE YOU...

ever filed bankruptcy? ____ ever been evicted? ____ ever been convicted of a felony? ___

Vehicle Make __________ Model ____________ Year _________ License ___________

Vehicle Make __________ Model ____________ Year _________ License ___________

Personal Reference ___________________ Address _____________________________

Phone ________________

Contact in Emergency _________________ Address _____________________________

Phone ________________

I declare that the statements above are true and correct. I authorize verification of my references and credit as they relate to my tenancy and to future rent collection.

Date _________________ Signed ___________________________________________

Verification SSN__DL/ID___CurTenancy___Prev__Credit___Inc___PersRefs___By___