Your name ____________________________________________________________
Your address ________________________ Soc. Sec. No. ______________________
Your home phone _____________________ Work Phone ______________________
Who lives with you? (include ages of children please) __________________________ _____________________________________________________________________
What pet(s) do you have? ________________________________________________
Do you have a waterbed? ________________________________________________
What vehicle(s) do you have? Make(s) _____________________________________
License(s) ______________________________________
Where do you work? (Company Name) ____________________________________
Where does your co-tenant work? _________________________________________
When did you move in? _________________________________________________
What is your current rent per month? _______________________________________
What date is your rent paid up to right now? _________________________________
When is your rent due each month? ________________________________________
What refundable deposits have you paid? Keys $ ________ Security $ ____________
Cleaning $ _________ Other (please explain) $ ______________________________
When you moved in, you paid your first month's rent. Did you also then pay your last month's rent? ________ If so, how much was it? $ ___________________
Which of the following furnishings in your dwelling belong to the owners of the building? (Please give room locations where appropriate)
Carpets ____________________________ Drapes ____________________
Shades ____________________________ Blinds _____________________
Stove ______________________________ Refrigerator ________________
Other appliances (Please list) ______________________________________
______________________________________________________________
Other Furniture (Please list) _______________________________________
______________________________________________________________
Do you have a rental agreement or lease in writing? ___________________________
If so, what is the date of the latest one ________________________________
In case of an emergency, what friend or relative should we contact?
Name ________________________________ Phone No. _______________
Date _______________ Your Signature ___________________________________
