Cars/Trucks/Motorcycles/Boats

Make

Model

Color

Year

License No.

Name of Bank

Branch Address

Account #

Date Account Opened

Credit References

Address / City

Phone

In Case of Emergency, Notify

Address / City

Phone

Relationship

Close Friend:

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 or had an unlawful detainer action filed against you?

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

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

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

5. Are you subject to any pending bankruptcy proceedings?

6. Have you, or anyone you know, past or present, resided at this address?

7. Do you propose to operate a business at this address?

8. If accepted, how long do you intend to stay?

9. Mother’s Maiden Name:

10. Spouse’s mother’s maiden name:

11. Do you have water a bed?

13. Please explain all (Yes) answers to general information:

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__________________________________________  Co-Applicant_____________________________________________

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

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

Previous Page                   ** Please print this form, sign and fax to us at (757) 467-6892. Thank you.