NOTE: A $50.00 application fee shall be payable to Mark C. DeBolt and will be applied to first month’s rent, if approved.

Social Security #_________________________Drivers License #_______________________State_______ Exp.________

Current Address______________________________________City____________________State_______Zip__________

Current Landlord’s name _________________________________________________ Phone #_____________________

How long at present address_________ Previous Address ________________________City ______________State_____

Previous Landlord’s name ______________________________________ How long at previous address______________

Auto Yr. _________ Make ________________ Model ________________ State/License plate # ____________________

Present Employer__________________________________Position_____________Supervisor_____________________

Employer’s Address___________________________________City_________________State______Zip______________

Phone # _____________________ How long at this job? _____________Monthly Income_________________________

Other Income/sources________________________________________________________________________________

Social Security #_________________________Drivers License #_____________________State ________ Exp. ________

Present Employer___________________________________Position_____________ Supervisor ___________________

Employer’s Address___________________________________City_________________State_______Zip_____________

Phone #____________________ How long at this job? _______________Monthly income_________________________

Other income/sources________________________________________________________________________________

Other household members: Name/Relationship/Age_______________________________________________________

Do you have any pets? _______ If so, how many, and what breed_____________________________________________

How many additional vehicles do you have? __________________________________________________

REFERENCES

Bank_____________________________ Address ____________________________________ Phone #______________

Nearest Relative___________________________Address______________________________ Phone #______________

 Have you ever been evicted from any tenancy? _______________

Have you ever willfully and intentionally refused to pay any rent when due? _______________________

I declare the foregoing statements to be true and factual.

I agree that Landlord may terminate any agreement entered into in reliance of any misstatement made above.

I agree that Landlord may make inquiries of any credit bureau as to my credit history.

I authorize any credit bureau to disclose any and all such information to Landlord.

 Applicant Sign: ______________________________________________________ Date ___________________________

 Co-Applicant Sign: ___________________________________________________ Date ___________________________