205 W. Moultrie Drive, Suite C, Blytheville, AR 72315
Call/Text (870) 495-8188 | www.capriblytheville.com | capriapts1@gmail.com
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Please fill out this application completely, leaving no blank spaces.  

If the question does not apply to you, please indicate with “NONE”.    

Please submit this Online Rental Application form or pick up a form at our office or download here.

Email (capriapts1@gmail.com) or drop off the following at the leasing office:

  • 2 Recent Pay Stubs or Proof of Income
  • A copy of your Driver’s license or State ID

How did you hear about Capri Apartments?
Are you interested in a 1 or 2 Bedroom?
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Head of Household 
(Name, BIrthdate, SSN)
Co-Head of Household
(Name, Birthdate, SSN, Relation with Head of Household - wife, sibling, etc. )
Other Roommate 
(Name, Birthday, SSN, Relation to Head of Household)
Marital Status
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Your Cell Number
Your Email
Current Address:(Address,City,State,Zip Code)
How Long have you been at this Address? Please also share why are you leaving or why you are needing an apartment at this time?
Address property type 
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Amount of Rent Paid per Month: $
Landlord's Name, Address, City, State, Zip, Phone

If you have NOT lived at the above current address 3 YEARS OR MORE, you MUST complete the following section of where you have lived for the past 3 years. Or Skip to the next question.


List your residential history for the past three years leading up to your current residence status below:

(Residence Address) / ( Landlord Name, Address, Telephone) / FROM  TO  (Include Month & Year)

Do you have any pets?  If yes, please share type and species.

Preferred Method of "Worry-Free" Standard Rental Payments:

Have you ever been evicted?    
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If yes, please explain:
Have you ever broken a lease?
Have you ever refused to pay rent for any reason?
Do you have renter's insurance?
Do you currently have any utilities in your name?
Do you currently have phone service in your name?
Is there anything to prevent you from placing utilities or phone in your name?
Will you agree to pay every month on time before the 5th of each month?
Do you know of anything or any reason which may interrupt your ability to pay rent?
Have you or any member of your household, ever been arrested?
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Have you ever had, or do you currently have a police record?
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Have you ever been convicted of a Felony?
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If yes to any of the above, please explain in detail:

Please Note: ONLY cars on application are authorized to be on premises.

Make/Model of Vehicle, License Plate Number
Make/Model of Vehicle, License Plate Number

Income History

Applicant's current employment status:
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Primary source of employment
Applicant employed by
Supervisor's name/ Cell Phone
Average weekly hours / How long at the place of employment?
Address/ Phone
Position / Salary  
Please indicate weekly, biweekly, monthly, or annual average take home pay.

Co-Applicant's current employment status :

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Co-Applicant Primary source of employment:
 Co-Applicant employed by
Supervisor's name/ Cell Phone
Average weekly hours/  How long at the place of employment?
Address/ Phone
Position/ Salary

OTHER SOURCE OF INCOME: (Please check all income sources that apply)

Social Security/ Amount: $/ Mo or Yr
SSI Disability/ Amount: $/ Mo or Yr
Pension/ Amount: $/ Mo or Yr
Part-Time Emp./ Amount: $/ Mo or Yr
Full Time Emp./ Amount: $/ Mo or Yr
Other Income/ Amount: $/ Mo or Yr
Do you have a Checking Account?  
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Two (2) credit references required. Please list in spaces below.
(Name of Institute/ Type of Loan/ Term of Loan/ Utility Company (City /State)/Service Location/ Service Dates)
(Name of Institute/ Type of Loan/ Term of Loan/ Utility Company (City /State)/Service Location/ Service Dates)

PERSONAL REFERENCES:  Provide two (2) persons NOT related to you, that you have known one (1) year or more. List in spaces below.

(Name/ Address/ Telephone No)
(Name/ Address/ Telephone No)
In the event of some emergency please list contact

1st Emergency Contact:

Name/ Relationship/Address/Phone Number

2nd Emergency Contact:

Name/ Relationship/Address/Phone Number

Thank you for completing an application to rent from Capri Apartments. 

*Please note that a completed application requires submission of the following, which will be copied and attached to this application.

_____ Driver's License or Picture ID. Note: Rentals will not be shown without picture ID.

_____ 2 Weeks of Most Current Pay Stubs of Each Income Source Listed

You can email these to capriapts1@gmail.com or drop off at the Leasing Office.

To complete application, the applicant will need to provide (2) proofs of income.  The applicant will need to go to district court building and pay $5.00 to get their background check.  If any information is found to be incorrect the application will be rejected and any subsequent rental agreement becomes void. False and misleading statements will be sufficient reason to not lease to applicant(s).

I/We hereby affirm that the foregoing information is true and correct to the best of my knowledge.

Signature of Head of Household
Please type your full name here.
Signature Date
Signature of Co-Head of Household
Signature Date
WARNING:  Section 1001 of Title 18, U.S. Code provides:  “Whoever, in any matter within the jurisdiction of any department or agency of the United States makes a false, fictitious, or fraudulent statement or representation, or makes or uses any false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000.00 or imprisoned not more than five (5) years, or both.”

 The Fair Housing Act, as amended, prohibits discrimination in the sale, rental, and financing of dwellings, and in other housing-related transactions, based on race, color, national origin, religion, sex, familial status (including children under the age of 18 living with parents of legal custodians, pregnant women, and people securing custody of children under the age of 18), and handicap (disability).  Complaints of discrimination may be forwarded to the Office of Fair Housing and Equal Opportunity, Department of Housing and Urban Development, Room 5204, 451 Seventh Street, SW, Washington, DC  20410-2000 or call (voice) 1-800-669-9777, 1-817-978-5900 or (TTY) 1-817-978-5595.

This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html or at any USDA office, or call (866)632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202)690-7442 or email at program.intake@usda.gov

A copy of your responses will be emailed to the address you provided.
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