Date: __________________

Application is hereby made to rent premises generally described as ___________________________________________________ for a term of _______ and ending the ____ day of _____________, 19____, for which monthly rental shall be $____________, payable in advance, and for which a security deposit of $_____________ shall be due prior to occupancy of the above-described premises.

A deposit of $________ 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: __________________________________________________________________________

Present Address: ____________________________________________ How Long? ___________

Previous Address: ___________________________________________ How Long? ___________

Married: ________ Spouse's Name: __________________________________________________

Children? ______________ How Many? _______________ Ages? _____________________

Pets? _______________ What Kind? ___________________ How Many? ___________

YOUR EMPLOYMENT

Employer: _____________________________________________________________________

Employer Address: ______________________________________________________________

Supervisor: _____________________________ Bus. Phone: _____________________________

How Long on Present Job? _________________________ Annual Income: _________________

SPOUSE'S EMPLOYMENT

Employer: ______________________________________________________________________

Employer Address: _______________________________________________________________

Supervisor: ______________________________ Bus. Phone: _____________________________

How Long on Present Job? ____________________ Annual Income: ______________________

REFERENCES

Bank: ________________________________________ Phone: ___________________________

Personal Reference: _____________________________ Phone: ___________________________

Credit Reference: _______________________________ Phone: ____________________________

Credit Reference: _______________________________ Phone: ____________________________

____________________________ 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 _________