PepZee Realty

Rental Application

(fax to 937-275-0003)

Today’s Date : _____________

Name(s) :______________________________________________

Current Address : _______________________________________

Address Applying for: ___ ________________________________

When do you want to move? (check one)

Now ___ 1st of Month___ After 1st____Other___

What Kind of Pets do you have (describe): ___________________________________________________

Applicant :

Last Name: ____________________ First: _______________

Middle Name: ________________ Maiden Name: _______________

Date of Birth: __________Social Security #: _____-____-_______

Telephone: (_____) _________________________

Driver’s License #: _______________Driver’s License State: ______

Identification #:_________________Identification State: _______

E-mail Address: ________________________________________

Other Occupants : (Include persons who regularly visit on an overnight basis

Name: ______________________________________

Date of Birth: __________________________

Social Security #:____-____-_______

Name: ______________________________________

Date of Birth: __________________________

Social Security #:____-____-_______

Name: _________________________________________

Date of Birth: _________________________

Social Security #:____-____-_______

Name: _________________________________________

Date of Birth: _________________________

Social Security #:____-____-_______

Vehicles :

License Plate #: ____________ State: _______ Make: __________

Year: ____________ Color: _________________

License Plate #: ____________ State: ________ Make: __________

Year: ____________ Color: _________________

Applicant’s Current Address :

Street: _________________________________Apt:________

City: ___________________ State: _______ Zip: ___________

Landlord’s Name: ______________________________________

Landlord’s Telephone: (______) ___________________________

Landlord’s Address: ____________________________________

City: _________________State: _________ Zip: ____________

Month & Year Moved In: ______________

Month & Year Moved Out: _____________

Rent per month: $_________Number of Bedrooms Rented: _______

Why are you moving? (check one)

Transferred ______________________________

More space ______________________________

Apt. to House ____________________________

Trouble w/Landlord _______________________

Other ___________________________________

Do you pay: (yes or no)

Heat (____) Cooking Fuel (____) Electric (____) Water (____)

Name used for billing by :

Gas Co: _______________________________________

Electric Co: ____________________________________

Water Co: ____________________________________

Telephone Co: ________________(for telephone #: ___________ )

Applicant’s Previous Address :

Street: _________________________________ Apt: ______

City: ________________________ State: _______ Zip: ______

Landlord’s Name: _________________________________

Landlord’s Telephone: (______) _____________________

Landlord’s Address: __________________________________

City: ______________________ State: _________ Zip: ______

Month & Year Moved In:_________ Month & Year Moved Out:______

Rent per month: $_________Number of Bedrooms Rented: _______

Applicant’s Previous Address :

Street: __________________________________ Apt: _______

City: _______________________State: _______ Zip: ________

Landlord’s Name: _______________________________________

Landlord’s Telephone: (______) _____________________

Landlord’s Address: ____________________________________

City: ______________________ State: _________ Zip: ______

Month & Year Moved In:_______ Month & Year Moved Out:________

Rent per month: $_________Number of Bedrooms Rented: _______

Job History

Current Employer: __________________________________

Supervisor: _______________________________________

Address: _________________________________________

City: ___________________ State: _________ Zip: ________

Telephone: (______) ___________________

Length of Time Employed: ______ years ______ months

Position: _________________________

Monthly Income: $_________________

Other Source of Current Income: __________________________ Monthly: $________________

Previous Employer:________________________________

Supervisor:____________________________

Address: __________________________________

City: ___________________ State: _________ Zip: _________

Telephone: (______) ___________________

Length of Time Employed: ______ years ______ months

Position: _________________________

Monthly Income: $_________________

Reason for Leaving: ___________________________________

Financial References :

Bank Name_____________________________________

Address______________________________________

Checking #___________________________

Savings #___________________________

Do you have any credit cards? Balance:

Gas _________________________ $________________

Dept. Store ____________________ $________________

Visa __________________________ $________________

Mastercard ___________________ $________________

American Express _______________ $________________

TOTAL: $___________________

Other Creditors: (Sample) Rent-A-Center, 123 Main st

Address__________________________________________

Account # ________________________________________

Balance $__________________Credit Limit $____________

Personal References and Contact Information (no relatives):

Name:___________________________________________

Phone: (_____)____________________________________

Address:_________________________________________

Name:____________________________________________

Phone: (_____)______________________________________

Address:__________________________________________

Name:_____________________________________________

Phone: (_____)_______________________________________

Address:____________________________________________

Closest Living Relative:

Name: _______________________________________________ Phone:(____) _____________Relationship:_____________________

In Case of Emergency Contact :

Name: ________________________Phone:(____)_________

Relationship: ___________________

Address: _____________________________________________

Name: ________________________Phone: (____)_____________

Relationship: ___________________

Address: _____________________________________________

Physician for Emergency:

Name: ___________________________ Telephone:(_ __)___________

Address: ______________________________________________

Name of Your Attorney:_______________________________________

Mother’s Maiden Name: _______________________________________

How Did You Hear About Us?

_________________________________________________________

1. If this Application is accepted do you have the first month rent and deposit? (___) Yes (___) No

2. If No, how much do you have now? $__________

3. Have you ever filed bankruptcy? (___) Yes (___) No

4. Have you ever been involved in any judgment or other legal proceedings (criminal, civil or other)? (___) Yes (___) No

5. Have you ever been served an eviction notice or been asked to vacate a property you were renting? (___) Yes (___) No

6. Have you ever willfully or intentionally refused to pay rent when due? (___) Yes (___) No

7. Have you ever changed your name? (___) Yes (___) No

8. Do you know of anything which may interrupt your income/ability to pay rent? (___) Yes (___) No

9. Is your credit good? (___) Yes (___) No

10. If your answer is “yes” to any of the above questions, please provide explanation below:

Explanation of Questions 1-10:

___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ _____________________________________________________

___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ _______________________________________________________

I have re-examined the information which I have provided on this application, and I agree that it is true and complete. I understand that providing false or incomplete information on this application shall be grounds for rejection of my application and/or immediate eviction.

By signing this application I agree:

1. Sign the Owner/Agent’s Lease Agreement and any related addendums within 3 days of acceptance of this application;

2. Pay my Security Deposit with a certified check, cashier’s check, or money order within 3 days of the acceptance of this application;

3. Pay the first monthly rental installment with a certified check, cashier’s check, or money order prior to receiving keys or taking occupancy.

4. I will have the appropriate utilities turned on before receiving keys or taking occupancy.

(please initial) DP&L______ Vectren_______ Water_______

I understand that if this application is accepted and I decide not to rent the residence, my deposit will be forfeited.

I further understand that if this application is not accepted, my deposit shall be returned.

Received from the applicant a non-refundable application fee of $_______ .

*Pets by Agreement Only* *NO WATERBEDS*

Applicant Signature:_______________________________Date:______________

Authorization to Release Information

Date__________________________

To Whom It May Concern:

I do hereby authorize PepZee Realty and/or its agents to obtain information concerning my past and present credit, rental or employment history. I hereby authorize any of the following sources including but not limited to (1) credit reporting agencies, (2) public or privately owned utility companies, (3) governmental housing agencies, and (4) current or past landlords, employers, physicians or creditors, to release any said information to the above named party. I hereby release any of the above sources, their officers, agents, or employees from any liability for damages of any kind whatsoever, whether caused by negligence or not, which may at any time result to me by reason of compliance with the above mentioned inquires, which may include the answering of specific questions and the giving of any information concerning my present or past record.

Additionally, I give the above named party permission to copy and submit this form as needed for the purpose of processing my rental application or to continue to get information for credit collections.

Signed: ____________________________ Date: __________________

Name: ___________________________________________________

Date of Birth: ____________ Social Security #: ________________

Address: ______________________________________________