RENTAL APPLICATION

For a term of 1 Year Lease, with renewal option. Desired date of occupancy:____________
Desired length of occupancy:__________________________
Reason for moving:_________________________________
The monthly rent shall be $$$___________ payable in advance.
The following deposits are required:
- Security deposit of $$$__________
- Pet deposit of         $$$__________
The total amount of $________including pet deposit, shall be due upon signature of the lease.
The Applicant understands that the Landlord will perform a credit check to verify the
Applicant's credit references and credit history in connection with the processing
of this Rental Application.
APPLICANT INFORMATION
Name: ________________________________________________________
No. of occupants:  Adults: _____Children: _____
Water bed:           Yes _____   No _____
Smokers:              Yes _____   No _____
Pets:                     Yes _____   No _____
    If so, what and how many?_____________
PRESENT ADDRESS: ________________________________
How long at present address: ________________________
Home Phone No.: (____)_______________
Landlord's Name: _________________________________
Phone No.:  (____)____________
Current rent payment: ____________
PRIOR ADDRESS: ____________________________________
How long at prior address: ____________________________
Landlord's Name: ___________________________________
Phone No.: (____)_____________________
Rent payment: ____________
Reason for moving: _________________________________
Ever convicted of a crime?______If so ,what date?____

PLEASE CIRCLE:  Single  –  Married  –  Divorced  -  Separated
Social Security No.: __________-_________-__________
Birth date : ______-______-______
PA Driver's License No. :__________________
Vehicle Model: _____________________Year: __________
License No.: ________________________
Vehicle Model: _____________________Year: __________
License No.: ________________________
SOURCES OF INCOME:

CURRENT EMPLOYER:
Employer:  _____________________________________________
Position: ____________________   How long: __________________
Supervisor: __________________  Business Phone: (____)________
Annual Income: _______________
PRIOR EMPLOYER:
Employer:  _____________________________________________
Position: ____________________   How long: __________________
Supervisor: __________________  Business Phone: (____)________
Annual Income:________________
NEAREST RELATIVE NOT LIVING WITH YOU:
Name:______________________________________________
Address: ___________________________________________
Home Phone No.: (____) ________________________________
Relationship: ________________________________________
PERSONAL REFERENCES:

BANK REFERENCES:
Name: ____________________________________
Branch: ___________________________________
Do you own real estate? 
Yes ____  No ____  If yes, please explain where:
Have you ever been evicted from any rental premises?
Yes ____  No ____  If yes, please explain:

Have you ever willfully and intentionally refused to pay rent when due?
Yes ____  No ____  If yes, please explain:
Are there any circumstances that may interrupt your income or ability to pay rent? 
Yes ____  No ____  If yes, please explain:
Have you ever been convicted of a felony? 
Yes ____  No ____  If yes, please explain
Please provide names of other tenants, including children and anyone
who will live with you, even if on a temporary basis.
Name: _______________________________
Birth date: ____-____-____PA Driver's License No. :__________
Adult: _____ Child______ Age: _____ Relationship: ___________
Occupation: _________________School/Grade: _____________
Name: _______________________________
Birth date: ____-____-_____PA Driver's License No. :_________
Adult: _____ Child______ Age: _____Relationship: ___________
Occupation: _________________School/Grade : ____________
I represent that the information provided in this Application is true and correct to the best of my knowledge. Jones Hardware 
is authorized to verify the references and employment information given in this Application and to request a credit check. 

_______________________________________        ______________
Applicant's Signature                                                                         Date

________________________________________      ______________
Co-Applicant's Signature                                                                    Date

IT IS AGAINST THE LAW TO DISCRIMINATE AGAINST PROSPECTIVE TENANT SON THE BASIS OF RACE, RELIGION, 
NATIONAL ORIGIN, AGE, DISABILITY OR FAMILY STATUS.  LOCAL OR STATE LAWS MAY INCLUDE ADDITIONAL 
CLASSES WHICH ARE PROTECTED FROM DISCRIMINATION IN HOUSING.       
Fax, email, or mail the application.  The application can be given  at the time of an appointment to view the 
home is scheduled.  Jones Hardware - 4276 State RT 147 - Herndon, PA 17830  
570 898 5731 cell  570-758-8822 Fax sales@joneshardware.com

Accepted: ________     Refused: _________

02/23/2012 04:39:57 PM