Cars/Trucks/Motorcycles/Boats

Make

Model

Color

Year

License No.

Bank Name

Branch Address

Account #

Date Account Opened

Credit Card #

Card Type (VISA/ MC/Other)

Creditor

In Case of Emergency, Notify

Address / City

Phone

Relationship

Reference Name:

Nearest Relative Living

Elsewhere

Please Answer yes (Y) or no (N) to each of the following and give explanations where necessary

Yes

No

1. Have you ever been evicted from any leased premises? If yes, when and why.

2. Have you ever left any lease premises owing money to Owner or Landlord? 

3. Have you ever refused to pay your rent for any reason?

4. Do you have any pets? (If yes, how many and what? - Explain Below)

 I am willing to pay a Pet Deposit and Pet Rent, and I am willing to sign a Pet Agreement.

5. Have you declared bankruptcy in the past five (5) years?

6. Are you subject to any pending bankruptcy proceedings?

7 Do you currently smoke?

8. Have you and/or intended occupants ever been sued for non-payment of rent?

9. Mother’s Maiden Name:

10. Spouse’s mother’s maiden name:

11. Do you have water a bed?

12. Have you ever left any lease premises owing money to Owner or Landlord?  Yes  No

13. Please explain all (Yes) answers to general information: Also state any relevant information you would like us to consider.

The owner of the premises you are applying for carries insurance on the dwelling only.  You must acquire renters insurance for your household goods. Neither the Agent nor the Owner of the property is responsible for damages to your personal property.

Each applicant certifies information provided is true and accurate to the best of their knowledge. Owner and Agent have each applicants permission to obtain credit history and verify any information provided. If any applicant withholds or gives false information, this application is considered void and the lease agreement may be terminated by the owner.

If the application is approved and the Applicants do not enter into a lease, any fees/deposits paid by the applicants may be retained by the agent. Full Security Deposit must be received in certified funds by  Agent within 24 hours after application approval. Property remains on the market until deposit is received. Application fees are non-refundable.

Owner and Agent are pledged to the letter and spirit of  U.S. policy for achievement of equal housing opportunity. We encourage and support affirmative advertising and marketing programs in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status, elderliness or national origin.

Megan’s Law Disclosure: (Applicants) should exercise whatever due diligence they deem necessary with respect to information on any sex offenders registered under Chapter 23 (19.2387 et seq.) of Title 19.2. Such information may be obtained by contacting your local police department or the Virginia State Police, Central Criminal Records Exchange, at (804) 674-2000 or on the Internet at www.state.va.us/vsp/vsp.html.

Each applicant understands that the agent represents the Owner of the premises and acknowledges having received a copy of this application at the time it was submitted.

 Applicant ____________________________  Date: ________  Co-Applicant _____________________________ Date: _________

I am aware that an incomplete application causes a delay in processing and may result in denial of residency.

Daytime (Phone):___________________________      Evening (Phone): _________________________________

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