RENTAL APPLICATION Page 1 of 3

The undersigned hereby makes an application to rent the home at:1106 Cheatham Ave, Springdale, AR 72764
Anticipated move date is: ________________________, at a monthly rent of $1250.00 & security deposit of $1000.00.
No pets allowed, no smoking. Optional: washer and dryer can be rented for $25 a month, tenant responsible for repairs.

PLEASE TELL US ABOUT YOURSELF

Full Name:__________________________________________________ Home Phone:_________________________

Date of Birth:____________________SS#:________________________ E-mail:_______________________________
Other Phone:______________________________________ Cell Phone:_____________________________________
Co-Applicant Name:__________________________Co-Applicant DOB:__________ SS#:________________________
Co-Applicant Name:__________________________Co-Applicant DOB:__________ SS#:________________________
Names of Dependents:_____________________________________________________________________________
Dependents’ Dates of Birth:__________________________________________________________________________
List ALL Pets:____________________________________________________________________________________

PLEASE GIVE RESIDENTIAL HISTORY (LAST 3 YEARS)

Current Address: ____________________________ Apt#:_____ City:__________________ State:____ Zip:________
Month/Year Moved In:____________ Reasons for leaving:______________________________ Rent: $_____________
Landlord/Owner:_________________________________________________ Phone:___________________________
Previous Address: ____________________________________________________________ Rent: $_____________
Landlord/Owner:_________________________________________________ Phone:___________________________
Previous Address: ____________________________________________________________ Rent: $_____________
Landlord/Owner:_________________________________________________ Phone:___________________________

PLEASE DESCRIBE YOUR CREDIT HISTORY (Reply for ALL Applicants)

Have you declared bankruptcy in the last 7 years? Yes_______ No_______
Have you ever been evicted from a rental residence? Yes_______ No_______
Have you had 2 or more late rental payments in the last year? Yes_______ No_______
Have you ever willfully or intentionally refused to pay rent when due? Yes_______ No_______

PLEASE PROVIDE YOUR EMPLOYMENT INFORMATION (Reply for ALL Applicants. Attach Page if Necessary)
Current status: ____Full time ____Part time ____Temp ____Student ____Unemployed ____Retired w/Pension
Employer & address: ________________________________________________________________________
Dates employed:__________________________________ Employed as:_____________________________________
Supervisor Name:_________________________Phone:__________________ Salary: $___________ per __________

Previous status: ____Full time ____Part time ____Temp ____Student ____Unemployed ____Retired w/Pension
Employer & address: ______________________________________________________________________________
Dates employed:__________________________________ Employed as:_____________________________________
Supervisor Name:_________________________Phone:__________________ Salary: $___________ per __________
If you have other sources of income that you would like us to consider, please list below. You do not have to list alimony,
child support, or spouse’s annual income unless you want us to consider it in this application.
Other income: Amount: $__________ Source/Contact name & number:______________________________________
Banking Accts: Name:__________________ Type of acct:__________________ Acct. No:______________________
Name:__________________ Type of acct:__________________ Acct. No:______________________
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PLEASE LIST YOUR REFERENCES

Personal References:
Name:___________________________________________ Relationship:____________________________________
Address:___________________________________________________________ Phone:_______________________
Name:___________________________________________ Relationship:____________________________________
Address:___________________________________________________________ Phone:_______________________
Name:___________________________________________ Relationship:____________________________________
Address:___________________________________________________________ Phone:_______________________

PLEASE LIST IDENTIFICATION & VEHICLE INFORMATION

Driver’s License: Your driver’s license number:______________________ State:_________ Expires:______________

Co-Applicant’s DL #: ____________________________ State:_________ Expires:______________
Dependent’s DL #:______________________________ State:_________ Expires:______________
Vehicle Information: Make/Model:_______________________ Year:_____ Lic. Plate #:________________ State:___
Only 3 vehicles Make/Model:_______________________ Year:_____ Lic. Plate #:________________ State:___
allowed. Make/Model:_______________________ Year:_____ Lic. Plate #:________________ State:___

MISCELLANEOUS QUESTIONS

Do you have any medical conditions that might prevent you from properly caring for this rental property (cleaning, water-
ing plants, maintaining)? If so, please explain:___________________________________________________________
If you are not able to properly care for this rental property, have you considered who will do so? Please explain:
________________________________________________________________________________________________
Smoking is not allowed in/outside this rental smoking is grounds for eviction. Is this a problem? Yes___ No___

NO PETS ALLOWED. Acquiring a pet will result in eviction. You acknowledge and accept this. Yes___ No___

We are NOT required by law to accept either ESA or Service animals since we have fewer than 3 rentals and we are
renting the property out ourselves, no broker or agency.

Landlord’s insurance does not cover damage or losses to your possessions in case of fire, flood, etc. We highly recom-
mend that you secure renter’s and/or liability insurance to cover your personal possessions, liability for damage caused
by yourself, dependents, or pets. Landlord is not responsible/liable for damage/loss to Tenants’ possessions or
personal items.
You must agree to a background check ONLY if you qualify to rent. This will include a credit check and screening for
criminal records, etc. You, the co-applicant and dependents (age 18 and over) will be screened. By submitting this ap-
plication you are giving permission for the background/credit screening(s). The background/credit check fee of
$25 is non-refundable.
ADDITIONAL INFORMATION

Additional info that might help landlord/owner evaluate this application:_______________________________________

________________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Where may we reach you to discuss this application? Day Phone: _________________Night Phone: ______________

Email addresses: Applicant 1_______________________________ Applicant 2________________________________

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APPLICATION CONFIRMATION AND DEPOSIT

I hereby apply to lease the above described for the term and upon the set conditions above set forth and agree that the rental is to be payable the first
day of each month in advance. As an inducement to the landlord/owner of the property to accept this application, I warrant that all statements above
set forth are true; however, should any statement made above be a misrepresentation or not true statement of facts, all of the security deposit will be
retained to offset the landlord/owner’s cost, time, and effort in processing my application.

If this application is not accepted in 5 business banking days I understand that I will not have not qualified to rent the home. When so approved and
accepted, I agree to execute a lease for a period of ONE YEAR before possession is given and to pay the first month’s rent, full security deposit, and
pet deposit/rent (if applicable) prior to the move in date. If the application is not approved or accepted by the landlord/owner, the application hereby
waives any claim for damages by reason of non-acceptance which the landlord/owner may reject. I recognize that as a part of the procedure for pro-
cessing my application, an investigative consumer credit report and background check will be prepared whereby information is obtained through per-
sonal interviews with others with whom I may be acquainted, or through a professional investigative or online background check service. This inquiry
includes information as to my character, general reputation, personal characteristics, and mode of living. Our apologies in advance if we do not contact
you to let you know that you have NOT qualified. We receive HUNDREDS of applications and we cannot possibly contact everyone who has not quali-
fied to rent.

The above information, to the best of my knowledge, is true and correct. X__________________________________ __________________
Applicant’s Signature Date

X__________________________________ ______________ X__________________________________ __________________

Primary Applicant’s Signature Date Applicant’s Signature Date

X__________________________________ ______________ X__________________________________ __________________

Cosigner Date Applicant’s Signature Date

BACKGROUND CHECK AUTHORIZATION

AUTHORIZATION FOR RELEASE OF INFORMATION

I agree to permit an investigation of my credit, tenant history, banking, employment, and police records for the purpose of renting a house with this
landlord/owner.

Your printed name on this application is your signature! _____________________________________________________ Date:_________________

Your printed name on this application is your signature! _____________________________________________________ Date:_________________

Your printed name on this application is your signature! _____________________________________________________ Date:_________________

ALL ADULT INDIVIDUALS WHO WILL BE RESIDING IN THIS HOME MUST SIGN THE APPLICATION, WILL BE RE-
QUIRED TO UNDERGO A BACKGROUND/CREDIT CHECK AT THEIR EXPENSE, AND WILL BE OBLIGATED TO
SIGN THE RENTAL AGREEMENT AS A CO-LESSEE. OWNER HAS THE RIGHT TO SEEK FINANCIAL AND LEGAL
RECOURSE FROM ANY AND ALL LESSEES. (In case of litigation, LESSEE(s) agree to pay for Landlord’s legal ex-
penses.) We do not accept arbitration as a means of addressing legal issues.

A scanned copy of this application can be submitted by e-mail to: patchoulimiss@gmail.com