Rental Application

Date and time received by landlord _____________________________________

This section to be completed by landlord

Address of Property to Be Rented: 3600 Old Forest Rd. #147, Lynchburg, VA 24502
Rental Term: [ ] month to month [ ] lease from __________ to __________
Amounts Due Prior to Occupancy
First months rent

$___________

Security deposit

$___________

Credit-check fee

$___________

Other (specify):

$___________
TOTAL:

$___________

Applicant
Full Nameinclude all names you use(d): __________________________________
Home Phone: ____________________ Work Phone: _____________________
Cell Phone: _____________________ Email: __________________________
Date of Birth: _________________________________________________________
Social Security Number: ________________________________________________
Drivers License Number/State: __________________________________________
Other Identifying Information: ___________________________________________
Vehicle Make: __________ Model: __________ Color: __________ Year: ________
License Plate Number/State: _____________________________________________

Rental Application

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Rental History
Current Address: _____________________________________________________
Dates Lived at Address: ________________ Reason for Leaving: ________________
Landlord/Manager: ___________________ Landlord/Manager's Phone: __________
Rent: $_____________________________ Security Deposit: $_________________

Previous Address: _____________________________________________________

Dates Lived at Address: ________________ Reason for Leaving: ________________
Landlord/Manager: ___________________ Landlord/Manager's Phone: __________
Rent: $_____________________________ Security Deposit: $_________________
References and Emergency Contact
Personal Reference: ______________________ Relationship: ________________
Address: _______________________________
_______________________________
Phone: ____________________________
Personal Reference: ______________________ Relationship: __________________
Address: _______________________________
_______________________________
Phone: ____________________________
Contact in Emergency: ____________________ Relationship: __________________
Address: _______________________________
_______________________________
Phone: ____________________________

Rental Application

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Employment History
Name and Address of Current Employer: __________________________________
__________________________________
Phone: ________________________________
Name of Supervisor: ____________________ Supervisor's Phone: _____________
Dates Employed at This Job: ______________ Position or Title: _______________

Name and Address of Previous Employer: __________________________________

__________________________________
Phone: ________________________________
Name of Supervisor: ____________________ Supervisor's Phone: _____________
Dates Employed at This Job: ______________ Position or Title: _______________
Income
1. Your gross monthly employment income (before deductions):

$__________

2. Average monthly amounts of other income (specify sources):

$__________

_____________________________________________________________________
_____________________________________________________________________
TOTAL:

$__________

Credit Card
Major Credit Card: [ ] VISA [ ] MC

[ ] Discover Card

[ ] Am Ex

[ ] Other: ____________________
Issuer: ________________________

Account No.: ________________________

Expiration Date: ________________________

Balance: $_________________

Average Monthly Payment: $____________________

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Bank/Financial Accounts
Bank/Institution
Savings Account

_________________________

Checking Account

_________________________

Other

_________________________

Loans
Type of Loan
(mortgage, car,
student loan, etc.)

Name of
Creditor

Monthly
Payment

______________

___________

____________

______________

___________

____________

______________

___________

____________

Miscellaneous
Describe the number and type of pets you want to have in the rental property:
_____________________________________________________________________
Do you smoke? [ ] yes

[ ] no

Have you ever: Filed for bankruptcy? [ ] yes [ ] no

How many times _____

Been sued?

[ ] yes [ ] no

How many times _____

Sued someone else?

[ ] yes [ ] no

How many times _____

Been evicted?

[ ] yes [ ] no

How many times _____

Been convicted of a
crime?

[ ] yes [ ] no

How many times _____

Explain any "yes" listed above: ___________________________________________

Source
Where did you learn of this vacancy?
_____________________________________________________________________

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Additional Occupants
List everyone, including children, who will live with you:
Full Name

Age and Relationship to Applicant

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

I certify that all the information given above is true and correct and understand that my
lease or rental agreement may be terminated if I have made any material false or
incomplete statements in this application. I authorize verification of the information
provided in this application from my credit sources, current and previous landlords and
employers, and personal references. I give permission for the landlord or its agent to
obtain a consumer report about me for the purpose of this application, to ensure that I
continue to meet the terms of the tenancy, for the collection and recovery of any financial
obligations relating to my tenancy, or for any other permissible purpose.

________________________________________________

__________________

Applicant Signature

Date

Notes (Landlord/Manager):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Rental Application

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