Southern Pines
PLEASE FILL IN ALL BELOW FIELDS
Tenant's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Drivers License Number
*
Phone
*
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Present Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at the above address?
*
Why are you moving?
Current Rent
*
Current Lease Expiration Date
*
-
Month
-
Day
Year
Date
Current Landlord Name(s)
*
Current Landlord Phone
*
Please enter a valid phone number.
Current Landlord Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3-Year Residential History
Please list all of the addresses you lived in for the past 5 years
*
Address
Start Date
Finish Date
Landlord's Name/Address/Phone
1
2
3
Other Tenants
*
Name
Social Security #
Age
Relationship
Occupation
1
Vehicle Information
*
Make
Model
Year
Color
License Plate Number
1
2
Employment/Financial Information
Tenant
Co-Tenant
Occupation
Employer
Business Address
Business Phone
Position/Title
Supervisor Name/Title/Phone
How long empoyed?
Gross Income
Payment Source(Wage/Commission/Salary/Tips/Govt Asst/Other)
Previous Employer
How long employed?
Bank Information
Bank Name
Account Number
Checking or Savings?
Branch
1
Visa/Mastercard Information
Visa or Mastercard?
Account Number
Issuing Bank
Limit
1
Personal References
*
Name
Address with City, State, Zip
Phone
Time of Acquaintance
1
2
3
Nearest Relative
*
Name
Address with City, State, Zip
Phone
1
Emergency Contact
*
Name
Address with City, State, Zip
Phone
1
Pet Information
*
Pet Name
Type/Breed
Color
1
2
Rate your cleanliness on a scale of 1(clean) to 5(dirty)
*
Do you smoke?
*
Yes
No
Do you smoke inside your home?
*
Yes
No
Have you ever been convicted of any crime?
*
Yes
No
If yes, please describe:
Have you ever been evicted from any tenancy ?
*
Yes
No
Have you ever filed a petition for bankruptcy?
*
Yes
No
If so, when?
Have you ever willfully and intentionally refused to pay rent when due?
*
Yes
No
If yes, please describe:
Today's Date
*
-
Month
-
Day
Year
Date
Is there any additional information about yourself that you would like to share? (ex. Skills, history, likes, dislikes, previous renting experiences, knowledge of home repair, etc.)
*
Discrimination
It is against the law to discriminate against tenants on the basis of race, religion, national origin, age, or neighborhood racial makeup.
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