Tenant Name 
Date of Birth
Social Security #
Mothers Maiden Name
Phone
Drivers License #
Present Address
How Long
Previous Address
How long
Monthly Income
Take-home Pay
Source (circle):
wages commission gov’t assistance salary tips other
Other Tenants
Name




Age
Relationship


Occupation
Name




Age
Relationship


Occupation
References
Have you ever been evicted?
Have you ever intentionally refused to pay rent when due?
I hereby certify that the answers I have given in this application are true and correct to the best of my knowledge. I understand that any false answers or statements made by me will be sufficient grounds for eviction and loss of any security deposit. Applicant permits and agrees to pay a fee of $10 for a credit check to be performed on him/herself and his/her co-occupant by his/her signature below.
Discrimination: It is against the law to discriminate against tenants on the basis of race, religion, national origin, age, or neighborhood racial makeup.