EMPLOYMENT INFORMATION I f employed less than two years, give same information on prior occupation

Present Occupation Employer Your Title Business Address Type of Business

Supervisor Supervisor's Phone Self-Employed DBA From To Monthly Gross

Prior Occupation Employer Your Title Business Address Type of Business

Supervisor Prior Supervisor's Phone Selp-Employed DBA From To Monthly Gross

REFERENCES

Housing

Rent Own Live with Parents Rent from Parents

Current Address Landlord/Agent Address

From To Phone Rent Amount

Previous Address Landlord/Agent Address

From To Phone Rent Amount

Personal

Name Address Nearest Relative Address

Phone Length of Aquaintance Phone Relationship

Have you ever filed a petition for bankruptcy?   Have you ever been evicted from any tenancy or had an eviction notice served on you?   Have you ever willingly and intentionally refused to pay any rent when due?  Have you ever been convicted of a misdemeanor or felony other than a traffic or parking violation? Are you current illegal abuser or addict of a controlled substance? Have you been convicted of the illegal manufacture or distribution of a controlled substance?  If yes to any of the above, please indicate date & nature of occurrence: I DECLARE THAT THE FOREGOING IS TRUE AND CORRECT, AUTHORIZE ITS VERIFICATION AND THE OBTAINING OF A CREDIT REPORT. I agree to pay the landlord a non-refundable screening fee not to exceed $30.00. I understand that I am entitled to a copy of any consumer credit report obtained by the Landlord. I further agree that the Landlord may terminate any agreement entered into in reliance on any misrepresentation made above.