Ghambers Management, lnc.

Phone: 319-351037
Name # of Present Address City, State, Zip Present Landlord Previous Address
Soc.Sec.# # of Children

cor?r1fi"tt1."h 241 . Fax: 3{gEZ-{g6O

Birthdate
# of Pets Kind Phone Apt # From Rent Pd/MO Apt # From Rent PdA{O

RENTALAPPLICATION

Occupants

# ofAdults

Phone #

City, State,Zip Previous Landlord Place of Employment Position Additional Source of Income
CREDIT REFERENCES:
Parents Name

Phone # Phone # How Long?

Contact IncomelN4O Amount/MO

(2)

(l)
Person

/ Emergency Contact

Address

City, State, Zip

Have you ever been convicted of a criminal offense other than

traffic violations?

lf yes, please explain

Are you on the sex offender registry or scheduled to be on the sex offender

registry?

If yes, ptease explain

Have you used or sold controlled substances illegally? Have you ever been evicted?

If yes, please explain

'l'he above information is truthful to the best of my knowledge. Misrepresentation of facts may be considered a breach of the Rental Agreement and grounds for termination at the discretion oithe Lan-<llord. I give Ciambers Managemen! Inc., permission to check into my credit history with Equifax lnformation Services LLC.

THERE IS A $2O.OO'NON.REFUNDABLE CASH fNO PERSONAL CHECKS} rTTEp. 4lPrircATroN FEE we also require a copy of a current state authorized photo ID.

PA%BL

Signed