EmailMe Form - RENTAL APPLICATION

Address You Are Applying For *

Street Address City State / Province / Region Postal / Zip Code

Move in Date *

MM / DD / YYYY

Are you working with a Realtor? *

Yes

No

If Yes, Please provide name and contact information:

Applicants Name *

Email *

Phone *

### - ### - ####

SOCIAL SECURITY NUMBER AUTHORIZATION

Applicants Name *

Applicants Address *

Social Security Number *

Date of Birth *

MM / DD / YYYY

I agree that Broker(s), his/her agent(s) and/or employee(s) may provide my social security number to lenders, title agencies, credit reporting companies, or others as necessary for obtaining reports or information from a credit reporting agency, determining the existence of domestic liens, obtaining a criminal background report (for prospective tenants only), ordering a mortgage payoff or for purposes of satisfying requirements of the Patriot Act.

CONSUMER UNDERSTANDS THAT BROKER HAS NO CONTROL OVER THE USE OF ANY INFORMATION AFTER IT IS DISCLOSED TO A THIRD PARTY. CONSUMER AGREES TO RELEASE AND HOLD BROKER HARMLESS FROM ANY AND ALL LIABILITY FOR ANY MISUSE OR SUBSEQUENT DISCLOSURE BY ANY THIRD PARTY OF THE INFORMATION OR REPORTS DISCLOSED BY BROKER PURSUANT TO THE TERMS OF THIS AUTHORIZATION.

Consumer's signature serves as an acknowledgement of receipt of a copy of this authorization.

Signature *

Clear

Date Signed *

MM / DD / YYYY

CURRENT RESIDENCE

If anything does not apply to you, enter N/A in the spaces.

Present Address / ZIP CODE *

*

Rent

Own

Other

Landlord Name *

First Last

Landlord Phone *

### - ### - ####

Monthly Rent / Mortgage *

From *

MM / DD / YYYY

To *

MM / DD / YYYY

PREVIOUS RESIDENCE

If does not apply - write N/A

Address / ZIP CODE *

*

Rent

Own

Other

Landlord Name *

First Last

Landlord Phone *

### - ### - ####

Monthly Rent / Mortgage *

From *

MM / DD / YYYY

To *

MM / DD / YYYY

ADDITIONAL APPLICANTS

Please add the names of each applicant applying with you.

Are you applying with anyone else 18 years or older? *

Yes

No

Applicants Name

Will a dependent or anyone under the age of 18 be living with you? *

Yes

No

Name

EMPLOYMENT INFORMATION

Provide at least three years of history. Attach additional files, if needed.

Attach proof of income, copy of paystub, employer letter, etc.

File Upload *

File Upload

Current Employer *

If anything does not apply to you, write N/A in the spaces

Supervisors Name *

First Last

Supervisors Phone *

### - ### - ####

Position *

Hours per week *

Hourly Rate *

Employed from *

MM / DD / YYYY

Employed to *

MM / DD / YYYY

Previous Employer *

If anything does not apply to you, write N/A in the spaces

Supervisors Name *

First Last

Supervisors Phone *

### - ### - ####

Position *

Hours per week *

Hourly Rate *

Employed from *

MM / DD / YYYY

Employed to *

MM / DD / YYYY

Previous Employer *

If anything does not apply to you, write N/A in the spaces

Supervisors Name *

First Last

Supervisors Phone *

### - ### - ####

Position *

Hours per week *

Hourly Rate *

Employed from *

MM / DD / YYYY

Employed to *

MM / DD / YYYY

Previous Employer *

If anything does not apply to you, write N/A in the spaces

Supervisors Name *

First Last

Supervisors Phone *

### - ### - ####

Position *

Hours per week *

Hourly Rate *

Employed from *

MM / DD / YYYY

Employed to *

MM / DD / YYYY

ADDITIONAL INCOME FOR MONTHLY EXPENSES

If not applicable, write N/A

Other: *

SSI, unemployment, SSD, food delivery service, child support, food stamps, death benefits

Amount *

Other: *

SSI, unemployment, SSD, food delivery service, child support, food stamps, death benefits

Amount *

Other: *

SSI, unemployment, SSD, food delivery service, child support, food stamps, death benefits

Amount *

Other: *

SSI, unemployment, SSD, food delivery service, child support, food stamps, death benefits

Amount *

BANK ACCOUNT INFORMATION

Bank Name *

Balance *

Bank Name

Balance

Available funds (not in bank) *

Current Bank Statement *

MONTHLY PAYMENTS

Additional monthly expenses

Car Insurance
Lender Name: *

Monthly Payment *

Balance Due *

Cell Phone
Provider: *

Monthly Payment *

Balance Due *

Credit Card
Lender Name: *

Monthly Payment *

Balance Due *

Personal Loan:

Monthly Payment

Balance Due

Other payments

VEHICLE

Include any cars, trucks, vans, motorcycles, trailers, boats and recreational vehicles.

Make/Model *

Year *

License Plate/State *

Color *

VEHICLE 2 Make/Model

Year

License Plate/State

Color

PETS

Does any Applicant or Occupant own any pets? (Guide and support animals not included) *

Yes

No

Type (cat, dog, etc.) / Breed / Age / Weight / Gender

If you have a cat, is it declawed?

Yes

No

OTHER INFORMATION

Have you ever declared bankruptcy or suffered foreclosure? *

Yes

No

Have you ever defaulted on your mortgage? *

Yes

No

Have you been evicted or sued for unpaid rent or damages to leased property? *

Yes

No

Have you ever refused to pay rent for any reason? *

Yes

No

Have you ever been convicted of or entered a plea of guilty or nolo contendere for a felony or misdemeanor? *

Yes

No

If answered "yes" to any of the above questions, please explain any answers below:
(If not applicable, write N/A) *

Since January 1, 1998, Have you been obligated to pay support under any order(s) or record? *

Yes

No

If "yes"

County:

Domestic Relations File or Docket Number:

Amount:

Are you delinquent?

CONDITION OF PROPERTY

The Property will be leased in the same condition as it is shown unless otherwise provided in the lease.

APPLICATION FEE

The Application Fee is NON-REFUNDABLE and will not be applied towards rent or other financial obligations should Applicant be approved, nor refunded if not approved. Applicant agrees that this sum is paid in consideration of Landlord/Broker for Landlord's review and/or verification of the information stated in the application.

OBLIGATION TO ENTER INTO LEASE AGREEMENT/DAMAGES

Upon submission of this Application, Landlord/Broker for Landlord reserves the right to remove property from the available rent list. If this application is denied by Landlord, the Application Deposit shall be refunded to Applicant. If this Application is approved and Applicant fails to rent the Property, Landlord shall be entitled to retain the Application Deposit.

CONVICTED SEX OFFENDERS (MEGAN'S LAW)

The Pennsylvania General Assembly has passed legislation (often referred to as "Megan's Law", 42 Pa.C.S. |9791 et seq.) providing for community notification of the presence of certain convicted sex offenders. Potential tenants are encouraged to contact the municipal police department or the Pennsylvania State Police for information relating to the presence of sex offenders near a particular property, or to check the information on the Pennsylvania State Police website at www.pameganslaw.state.pa.us

NOTICE TO PERSONS OFFERING TO SELL OR RENT HOUSING IN PENNSYLVANIA

(A) Federal and state laws make it illegal for Landlord, Broker, or anyone to use RACE, COLOR, RELIGION or RELIGIOUS CREED, SEX, DISABILITY (physical or mental), FAMILIAL STATUS (children under 18 years of age), AGE (40 or older), NATIONAL ORIGIN, USE OR HANDLING/TRAINING OR SUPPORT OR GUIDE ANIMALS, or the FACT OR RELATIONSHIP OR ASSOCIATION TO AN INDIVIDUAL KNOWN TO HAVE A DISABILITY as it reasons for refusing to sell, show, or rent properties, loan money, or set deposit amount, or as reasons for any decision relating to the sale of property. The municipality in which the property is located may have enacted an ordinance or other law that extends the protections for access to housing to additional classes of individuals, such as gay, lesbian, bisexual and transgender individuals and couples. Broker and Landlord are advised to check with your local municipality, representative from Pennsylvania Human Relations Commission, or your own attorney for further guidance.

(B) The Fair Housing Act prohibits rental practices which have a discriminatory effect on members of protected classes, including outright bans on offering housing to individuals based on arrests or convictions without a case-by-case assessment of relevant mitigating factors. Consideration of an applicant's criminal history must be limited to convictions and should include an evaluation of the nature and severity of the offense, the amount of time that has passed since the criminal conduct occurred, and whether denial of the application will serve a substantial, legitimate, nondiscriminatory interest. Selective use of an applicant's criminal history as a pretext for intentional discrimination based on race, national origin, or other protected characteristics may be a violation of the Act, as well.

SPECIAL CLAUSES

If the Landlord or Broker denies your application based in whole or in part on any information contained in the consumer report authorized by paragraph 16 of this Application, the Landlord or Broker must provide you with oral, written or electronic notice of the denial, and must provide to you: (1) the name, address, and telephone number of the consumer reporting agency (including a toll-free telephone number established by agency if the agency complies and maintains files on consumers on a nationwide basis) that furnished the report, (2) a statement that the consumer reporting agency did not make the decision to deny the application and is unable to provide you with specific reasons why your application was denied, (3) a numerical credit score, the range of possible credit scores under the model used, up to four key factors that led to the denial, and the date the credit score was created (4) information about how to obtain a free copy of your consumer report from the consumer reporting agency, and (5) information about how to dispute the accuracy or completeness of any information in a consumer report furnished by the agency. If the Landlord or Broker denies your application because of information from a person other than a credit reporting agency (for example, an employer or prior landlord), the Landlord or Broker must provide you with notice about your right to make a written request to discover the nature of that information.

FAIR CREDIT REPORTING ACT

A description of the section goes here.

AUTHORIZATION

By checking the boxes below, Applicant makes the following authorization:

Applicant authorizes Landlord or Broker for Landlord to obtain any information deemed necessary to evaluate this Application. This information may include, but is not limited to, credit reports, criminal history, judgements or record, rental history, verification of employment and salary, employment history, vehicle records, and licensing records. Broker for Landlord may report to Landlord any information obtained by Broker for Landlord for evaluation of the Application. Applicant acknowledges that all information in the Application is true and correct. Applicant acknowledges that if applicant presents false or incomplete information Landlord may reject this Application. Applicant understands that giving false or incomplete information may result in forfeiture of any payments made in connection with this Rental Application. *

Yes

Applicant understands and acknowledges that Applicant's social security number, driver's license number, date of birth, or other personal identifying information may be required in order for Landlord or Broker for Landlord to evaluate this application. If requested, Applicant agrees to provide the information on a separate form such as the Social Security Number Authorization (PAR Form SSA). Failure to provide this information may result in denial of your Application. *

Yes

Applicant agrees that Broker(s), his/her agent(s) and/or employee(s) may provide Applicant's social security number, individual taxpayer identification number, driver's license information and date of birth to lenders, title agencies, credit reporting companies, or others as necessary for obtaining reports or information from a credit reporting agency, determining the existence of domestic liens, or for obtaining a criminal background report (for prospective tenants only). Applicant understands that Brokers have no control over the use of any information after it is disclosed to a third party and agrees to release and hold Brokers harmless from any and all liability for any misuse or subsequent disclosure by any third party of the information or reports disclosed by Broker pursuant to the terms of this authorization. *

Yes

Applicant authorizes the Broker for Landlord to contact the Applicant directly. *

Yes

I HAVE READ AND AGREE TO THE PROVISIONS AS STATED.
Signature *

Clear

Additional information you would like us to consider while reviewing application *

N/A if not applicable

CONSUMER NOTICE
In an effort to enable consumers of real estate services to make informed decisions about the business relationships they may have with real estate brokers and salespersons (licensees), the Real Estate Licensing and Registration Act (RELRA) requires that consumers be provided with this Notice at the initial interview.

Licensees may enter into the following agency relationships with consumers:
Seller Agent
As a seller agent the licensee and the licensee's company works exclusively for the seller/landlord and must act in the seller's/landlord's best interest, including making a continuous and good faith effort to find a buyer/tenant except while the prop- erty is subject to an existing agreement. All confidential information relayed by the seller/landlord must be kept confidential except that a licensee must reveal known material defects about the property. A subagent has the same duties and obligations as the seller agent.
Buyer Agent
As a buyer agent, the licensee and the licensee's company work exclusively for the buyer/tenant even if paid by the seller/landlord. The buyer agent must act in the buyer/tenant's best interest, including making a continuous and good faith effort to find a property for the buyer/tenant, except while the buyer is subject to an existing contract, and must keep all confidential information, other than known material defects about the property, confidential.
Dual Agent
As a dual agent, the licensee works for both the seller/landlord and the buyer/tenant. A dual agent may not take any action that is adverse or detrimental to either party but must disclose known material defects about the property. A licensee must have the written consent of both parties before acting as a dual agent.
Designated Agent
As a designated agent, the broker of the selected real estate company designates certain licensees within the company to act exclusively as the seller/landlord agent and other licensees within the company to act exclusively as the buyer/tenant agent in the transaction. Because the broker supervises all of the licensees, the broker automatically serves as a dual agent. Each of the desig- nated licensees are required to act in the applicable capacity explained previously. Additionally, the broker has the duty to take reasonable steps to assure that confidential information is not disclosed within the company.

In addition, a licensee may serve as a Transaction Licensee.
A transaction licensee provides real estate services without having any agency relationship with a consumer. Although a transac- tion licensee has no duty of loyalty or confidentiality, a transaction licensee is prohibited from disclosing that:
• The seller will accept a price less than the asking/listing price,
• The buyer will pay a price greater than the price submitted in the written offer, and • The seller or buyer will agree to financing terms other than those offered.
Like licensees in agency relationships, transaction licensees must disclose known material defects about the property.
12/08
• Regardless of the business relationship selected, all licensees owe consumers the duty to:
• Exercise reasonable professional skill and care which meets the practice standards required by the RELRA.
• Deal honestly and in good faith.
• Present, as soon as practicable, all written offers, counteroffers, notices and communications to and from the parties. This duty may be waived by the seller where the seller's property is under contract and the waiver is in writing.
• Comply with the Real Estate Seller Disclosure Law.
• Account for escrow and deposit funds.
• Disclose, as soon as practicable, all conflicts of interest and financial interests.
• Provide assistance with document preparation and advise the consumer regarding compliance with laws pertaining to real estate transactions.
• Advise the consumer to seek expert advice on matters about the transaction that are beyond the licensee's expertise.
• Keep the consumer informed about the transaction and the tasks to be completed.
• Disclose financial interest in a service, such as financial, title transfer and preparation services, insurance, construction, repair or inspection, at the time service is recommended or the first time the licensee learns that the service will be used.
• The following contractual terms are negotiable between the licensee and the consumer and must be addressed in an agree- ment/disclosure statement:
• The duration of the licensee's employment, listing agreement or contract. • The licensee's fees or commission.
• The scope of the licensee's activities or practices.
• The broker's cooperation with and sharing of fees with other brokers.
• All sales agreements must contain the property's zoning classification except where the property is zoned solely or primarily to permit single family dwellings.
• The Real Estate Recovery Fund exists to reimburse any person who has
obtained a final civil judgment against a Pennsylvania real estate licensee owing to fraud, misrepresentation, or deceit in a real estate transaction and who has been unable to collect the judg- ment after exhausting all legal and equitable remedies. For complete details about the Fund, call (717) 783-3658.

Adopted by the State Real Estate Commission at 49 Pa. Code §35.336.

If this application is approved and a deposit is collected, and applicant fails to rent property - landlord shall be entitled to obtain deposit monies as damages.

By checking the box below, I agree to pay the application fee of $35 per applicant 18 years or older. *

Yes