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Your name ____________________________________________________________

Your address ________________________ Soc. Sec. No. ______________________

Your home phone _____________________ Work Phone ______________________

Who lives with you? (include ages of children please) __________________________ _____________________________________________________________________

What pet(s) do you have? ________________________________________________

Do you have a waterbed? ________________________________________________

What vehicle(s) do you have? Make(s) _____________________________________

License(s) ______________________________________

Where do you work? (Company Name) ____________________________________

Where does your co-tenant work? _________________________________________

When did you move in? _________________________________________________

What is your current rent per month? _______________________________________

What date is your rent paid up to right now? _________________________________

When is your rent due each month? ________________________________________

What refundable deposits have you paid? Keys $ ________ Security $ ____________

Cleaning $ _________ Other (please explain) $ ______________________________

When you moved in, you paid your first month's rent.  Did you also then pay your last month's rent? ________  If so, how much was it? $ ___________________

Which of the following furnishings in your dwelling belong to the owners of the building? (Please give room locations where appropriate)

               Carpets ____________________________               Drapes ____________________

               Shades ____________________________  Blinds _____________________

               Stove ______________________________              Refrigerator ________________

               Other appliances (Please list) ______________________________________


               Other Furniture (Please list) _______________________________________


Do you have a rental agreement or lease in writing? ___________________________

               If so, what is the date of the latest one ________________________________

In case of an emergency, what friend or relative should we contact?

               Name ________________________________ Phone No. _______________



Date _______________         Your Signature ___________________________________


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