Broker/Landlord

RENTAL APPLICATION
The Consumer Notice 49 Pa. Code §35.336 should be provided before completing this form.
Applicant's Relationship with PA Licensed Broker
WHAT IS THE APPLICANT’S RELATIONSHIP WITH PA LICENSED BROKER

No Business Relationship (Applicant is not represented by a broker)
WHAT IS THE APPLICANT'S RELATIONSHIP WITH PA LICENSED BROKER

No Business Relationship (Applicant is not represented by a broker)
Broker (Company)
Company License #
Company Address 1

Address 1

Address 2

CityState

Postal / Zip Code
Company Phone
Company Fax
Broker is (check only one)

Tenant Agent (Broker represents Appplicant only)Dual Agent (See Dual and/or Designated Agent box below)Transaction Licensee (Broker and Licensee(s) provide real estate services but do not represent Applicant)
Licensee (Name)
Licensee State License #
Licensee Direct Phone(s)
Licensee Cell Phone
Licensee Email
example@example.com
Licensee(s) is (check only one)

Tenant Agent (all company licensees represent Appplicant)Tenant Agent with Designated Agency only Licensees namedDual Agent (See Dual and/or Designated Agent box below)

Landlord's Relationship with PA Licensed Broker
LANDLORD’S RELATIONSHIP WITH PA LICENSED BROKER

No Business Relationship (Landlord is not represented by a broker)
Broker (Company)
Company License
Company Address 2

Address 1

Address 2

CityState

Postal / Zip Code
Company Phone
Company Fax
Broker is (check only one)

Landlord Agent (Broker represents Landlord only)Dual Agent (See Dual and/or Designated Agent box below)Transaction Licensee (Broker and Licensee(s) provide real estate services but do not represent Landlord)
Licensee(s) (Name)
State License #
Direct Phone(s)
Cell Phone(s)
Email
example@example.com
Licensee(s) is (check only one)

Landlord Agent (all company licensees represent Landlord)Landlord Agent with Designated Agency only LicenseesDual Agent (See Dual and/or Designated Agent box below)

Property Information

To be supplied by Broker for Landlord
Property Address

Address 1

Address 2

CityState

Postal / Zip Code
Move-in Date

MonthDayYear
Date
Term
Application Fee (non-refundable)
Application Deposit
Monthly Rent
Security Deposit
First Month’s Rent
Last Month's Rent
Rent and Security Deposit checks will be written separately.
Are pets permitted? Note: The term "pets" does not include guide or support animals. (May be subject to review)

YesNo
Non-refundable Pet Fee
Pet Rent
Other Fee Description
Other Fee - Amount
Other Fee 2 Description
Other Fee 2 - Amount
Is rental insurance required for tenants?

YesNo

DUAL AND/OR DESIGNATED AGENCY
A Broker is a Dual Agent when a Broker represents both Landlord and Tenant in the same transaction. A Licensee is a Dual Agent when a Licensee represents Landlord and Tenant in the same transaction. All of Broker’s licensees are also Dual Agents UNLESS there are separate Designated Agents for Landlord and Tenant. If the same Licensee is designated for Landlord and Tenant, the Licensee is a Dual Agent.

By signing this agreement, landlord and Tenant each acknowledge having been previously informed of, and consented to, dual agency, if applicable.
Applicant’s Initials
Please check this box to acknowledge you have completed all relevant parts of this application.*

I have completed all relevant parts of this application.

RENTAL APPLICATION