Pennsylvania Rental Application Form Page 2
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28. CURRENT LOANS AND OBLIGATIONS
Company or Person
Reason
Time Left
Monthly Amount
$
$
Total
9. FINANCIAL REFERENCES
Name
Address
Account No.
Bank
Savings:
Checking:
Charge Account
Charge Account
10. PERSONAL REFERENCES
Name
Relationship
Address
Phone
In Case of Emergency, Notify:
11. GENERAL
Have you received welfare assistance within the last two years? ............................................................................................................................... ❐ Yes ❐ No
Have you received unemployment compensation within the last two years? ............................................................................................................. ❐ Yes ❐ No
Are you eligible for any governmental housing subsidy? ........................................................................................................................................... ❐ Yes ❐ No
Have you ever been ejected for non-payment of rent or otherwise failed to meet your lease obligations? If Yes, explain in remarks. .................... ❐ Yes ❐ No
Have you ever been convicted or pleaded guilty or “no contest” to a felony (whether or not resulting in conviction)?
If Yes, explain in remarks. ...................................................................................................................................................................................... ❐ Yes ❐ No
Have you ever been convicted or pleaded guilty or “no contest” to a misdemeanor involving sexual misconduct (whether or not
resulting in conviction)? If Yes, explain in remarks. ..................................................................................................................................
❐ Yes ❐ No
12. REMARKS
13. RENTAL INFORMATION
How Did You Hear About This Rental Unit?
❐
❐
❐
❐
Classified Newspaper Ad
Yellow Pages
Internet Listing
Saw Rental Unit While Driving By
❐
❐
❐
Web Site
Personally Recommended
Other
I CERTIFY THAT the above information supplied is true and complete to the best of my knowledge. I authorize verification of all information given;
and understand that additional information will be obtained from the Apartment Association of Northwestern Pennsylvania, Inc., the Credit Bureau, and
other services. I understand that my rent payment record, my performance of rules and lease obligations, and my treatment of the premises will be
reported to credit reporting agencies and to other landlords.
I understand that this application may be accepted or rejected at the discretion of the landlord. I understand and agree that rents and deposits paid
toward the rental unit will be refunded only if this application is rejected by the landlord; and that otherwise, those rents and deposits will be applied as
specified in the lease agreement.
Date:
Signatures:
DISCLAIMER
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