Name:                          

Social Security #:          

Birthdate:                    

Drivers License #:         

    (mail or fax copy of license with application)

Occupation:                  
(If Student, est. graduation date: 

Place of Employment:    

Employer's Name:          

Employment Phone #:    

Current Landlord:          

Landlord Phone #:         

Current Address:           

City:                              State:

Zip:                             

Current Phone #:           

Cell Phone#:                 

Email:                          

Parents Name:              

Parents Address:                                             City, State & Zip:            

Parents Phone #:          

Reason for leaving current address:

Names of People includes as Tenants: (Limit 2 people)

Preferred move-in date:

List Current Income Amount, Supervisor and Phone # for Verification:

I understand that by submitting a rental payment for an apartment, that I have committed to a one year agreement, subject to application verification, credit/background check, and approval, and will lose my rental payment if I change my mind.  I give my permission for a credit/background check for the purpose of this rental.

(SIGNATURE REQUIRED-may be evidenced by facsimile)

______________________________________________________________________

WE RESERVE THE RIGHT TO REFUSE SERVICE TO ANYONE.

Please fill out this form, print it and fax to: 318-254-1198. This form cannot be submitted via the Internet.