"Employer Landlord Work Reference Rent"
MIDDAUGH REAL ESTATE INC. 163 North Main Street, Wellsville, NY Phone 585-593-3457 Fax 585-593-4189 RENTAL APPLICATION LANDLORD INFORMATION ONLY Address of Property to be Rented: Amounts Due Prior to Occupancy: First Month's Rent: $ Security Deposit: $ TOTAL $ Applicant Information: Name (First) (Middle) (Last) Home Phone: ( ) Work Phone: ( ) ADDITIONAL OCCUPANTS: List everyone who will be living with you: Full Name: Relationship to Applicant: RENTAL HISTORY: Current Address: Dates lived at current address: Reason for leaving: Landlord/Manager: Landlord/Manager's Phone: ( ) Previous Address: Dates lived at current address: Reason for leaving: Landlord/Manager: Landlord/Manager's Phone: ( ) EMPLOYMENT HISTORY: Name and Address of Current Employer: Name of Supervisor: Supervisor's Phone: Dates Employed at this job: Position or Title: MISCELLANEOUS: Do you smoke? yes no Have you ever: yes no Filed for Bankruptcy? yes no Been Sued? yes no Been Evicted? yes no Been Convicted of a Crime? yes no If yes, please explain: REFERENCES AND EMERGENCY CONTACT: Personal Reference: Name: Phone: ( ) Address: Relationship: Personal Reference: Name: Phone: ( ) Address: Address: Relationship: Contact in Emergency: Name: Phone: ( ) Address: Relationship: I certify that all the information given above is true and correct and understand that my rental agreement may be terminated if I have made any false or incomplete statement in this application. I authorize verification of my credit history and the information provided in this application from credit bureaus, current and previous landlords and employers and personal references. Applicant's Signature Date