P O B o x 4 2 2 / 2 7 M a i n S t r e e t S a l a m a n c a, N Y 1 4 7 7 9

7 1 6 – 9 4 5 – 8 5 6 5 (phone) 7 1 6 – 9 4 5 – 1 3 8 5 (Fax)
Rental Application
Date: ____________________ How did you hear about us: __________________________________
Date Desired: _____________ Price Range: ________________ Rental Type Desired: ____________

Applicant: Co-Applicant:
Full Name: _______________________________ Full Name: __________________________ ____
Date of Birth:___________ SS#:______________ Date of Birth:___________ SS#:____________
D.L. #_______ State: ____ Tribal # (if applicable) ______ D.L. #______ State: ___ Tribal # (if applicable) _____
Phone: ______________ Cell: _______________ Phone: _____________ Cell: _____________
Additional Occupants (Please provide full names of all additional individuals, relationship and ages, including children):
Name: _________________________ Relationship: _______________________ Age______
Name: _________________________ Relationship: _______________________ Age______
Name: _________________________ Relationship: _______________________ Age______
Name: _________________________ Relationship: _______________________ Age______

Current Residence:
Street: ___________________________City: ______________________State: ___________ Zip: _______
Present Landlord: _________________________________ Phone: __________________
Address:____________________________ City:______________________ State:________ Zip:__________
Dates lived at this address: _______________Own: _____Rent: _____Occupy:____ Monthly Pmt: ______
Security Deposit Held: _______ Security Deposit Ret’d: _______ Reason for moving: ________________
Previous Residence:
Street: ___________________________City: ______________________State: ___________ Zip: _______
Landlord: _________________________________ Phone: __________________
Address:____________________________ City:______________________ State:________ Zip:__________
Dates lived at this address: _______________Own: _____Rent: _____Occupy:____ Monthly Pmt: ______
Security Deposit Held: _______ Security Deposit Ret’d: _______ Reason for moving: ________________
Previous Residence:
Street: ___________________________City: ______________________State: ___________ Zip: _______
Landlord: _________________________________ Phone: __________________
Address:____________________________ City:______________________ State:________ Zip:__________
Dates lived at this address: _______________Own: _____Rent: _____Occupy:____ Monthly Pmt: ______
Security Deposit Held: _______ Security Deposit Ret’d: _______ Reason for moving: ________________
Preferred Rental Preference:
How long do you plan on living in the rental home? ______________ Any water-filled furniture? ________
How many pets do you have? __________Type: ________________________________________________
Have you ever broken a lease? _________ Have you ever been evicted/asked to leave a rental unit?______
Have you ever refused to pay rent for any reason?____ If so, why?________________________________
Have you ever filed for bankruptcy? _____ Have you ever been convicted of a crime? ________________
Do you give us permission to do a criminal background check?_________________

**Confidential Page 1 of 3 Pages Confidential**

Income History * * M u s t p r o vi d e p r o o f * *
Current employment status: F/T:____P/T (32 hrs or less):____Student: ____ Retired: ____Self-Employed: ___Unemployed: ____ Other:___________
Employment Information (Applicant) **Please list any income, other than employment in “Additional Income” section**
Name of Employer: _____________________ Supervisor’s Name: _______________ Phone:_____________
Address:____________________________ City:______________________ State:________ Zip:__________
Average Hours: _______ Length of Employment: _________ Salary: _________ Position: ___________
Employment Information (Co-Applicant)
Name of Employer: _____________________ Supervisor’s Name: _______________ Phone:_____________
Address:____________________________ City:______________________ State:________ Zip:__________
Average Hours: _______ Length of Employment: _________ Salary: _________ Position: ___________
Additional Income
Source:______________ Amount: _________ Contact person: _________________ Ph: _________
How long:___________ How long do you expect income to continue: _____________________

Vehicle Information
Auto#1: Year_____Make___________ Model___________ Color___________Plate #:___________
Auto#2: Year_____Make___________ Model___________ Color___________Plate #:___________
* * Pl ea se n o t e, o n ly ca rs o n a p p li ca t i o n a re a u t h o ri zed t o b e o n p remi ses* *

Do you have any commercial vehicles, campers, boats, or motorcycles? ______

Financial Information
Checking: Bank & Branch Location:__________________ Phone:____________ Account #____________
Savings: Bank & Branch Location:__________________ Phone:____________ Account #____________
Auto Loan: Lender:___________________ Phone:____________ Account #____________
Card Loan Creditor: Lender:___________________ Phone:____________ Account #____________
Character/Personal Reference (other than relatives):
1.) Name: _________________________ Relationship: _______________ Phone: _______________
Address:_________________________ City:______________________ State:________ Zip:__________
2.) Name: _________________________ Relationship: _______________ Phone: _______________
Address:_________________________ City:______________________ State:________ Zip:__________
Professional Reference (e.g., attorney, accountant, etc.):
Name: _____________________________ Phone: ___________________ Relationship: ________________
Address:____________________________ City:______________________ State:________ Zip:__________
Name of Nearest Living Relative / Emergency Contact Information:
Name: __________________________ Phone: _____________________ Relationship:_______________
Address:____________________________ City:______________________ State:________ Zip:__________
Phone ______________________________Additional phone: ____________________
Do you give owner/manager permission to contact the references listed above both now and in the future for rental consideration or for collection purposes should that be deemed necessary? ______

Applicant acknowledges this application will become part of the lease agreement when approved. I further understand that false, fraudulent
or misleading information disclosed or omitted or incomplete information may be grounds for denial of tenancy or subsequent eviction and
therefore rental agreement becomes void.

Applicant’s signature: ______________________________________Date: _____________________

Applicant’s signature: ______________________________________Date: _____________________

**Confidential Page 2 of 3 Pages Confidential**

 (ver. 12.17.09)

Authorization to Release Information

In connection with my application for tenancy, I have been advised and I hereby consent and authorize Salamanca Rentals Property Management and
its agent, at any time during my application process and/or tenancy, to conduct an investigative consumer report that may include, but not be limited
to, a criminal record check, employment verifications, verifications of personal references and reputation, and to obtain information from
current/previous landlords. I do hereby consent and authorize Salamanca Rentals Property Management and its agent to use any information provided
on this form or during the application process in performing the investigative consumer report to evaluate the rental application and determine my
fitness as a prospective client. I agree to release, indemnify and hold harmless Salamanca Rentals Property Management and any consumer reporting
agency used by Salamanca Rentals Property Management with regard to any information reported by the consumer reporting agency. I understand
that upon timely written request to Salamanca Rentals Property Management, the name, address and telephone number of the consumer reporting
agency and the nature and scope of the investigative report will be disclosed to me. I acknowledge that facsimile, copy or email of this document
shall have the same validity, force and effect as the original. This permission will survive the expiration of the tenancy and may be accessed for any
legitimate business purpose related to the tenancy.

The following are my responses to questions about my criminal history, if any. (Exclude minor traffic offenses punishable
only by fine.) IF YOU ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS, ATTACH DETAILS ON A SEPARATE SHEET OF PAPER TO
INCLUDE THE STATE, COUNTY, DATE OF OFFENSE, AND DETAILS OF THE CONVICTION.

1. Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? ____Yes ____No

2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense? ____Yes ____No

3. Have you ever received probation or community supervision for any federal, state or municipal offense? ____Yes ____No

4. As of the date of this consent form, do you have any pending charges against you? ____Yes ____No

I hereby certify that all information provided is true, correct and complete. If any information proves to be incorrect or incomplete, I understand that
grounds for rejection of services from Salamanca Rentals Property Management.

Acknowledged: Acknowledged:
This _____ day of _________________, 20____ This _____ day of _________________, 20____

__________________________________ ___________________________________
Signature Signature

__________________________________ ___________________________________
Printed Name Printed Name

__________________________________ ____________________________________
Social Security # Social Security #

__________________________________ ____________________________________
Address Address

_________________________________________ ___________________________________________
City, State, ZIP City, State, ZIP
**Confidential Page 3 of 3 Pages Confidential**