Directory Registration Form

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OFF-CAMPUS HOUSING DIRECTORY
2016-2017
REGISTRATION FORM
* One Registration Form per rental unit *
(PLEASE PRINT) PLEASE RETURN TO OUR OFFICE AS SOON AS POSSIBLE.
Landlord (Last Name)
(First Name)
(Middle Initial)
Landlord’s Mailing Address
(City)
(State)
(Zip)
Home or Business Telephone
Cell Phone
(E-mail Address)
(Housing Website)
(
)
(
)
Address of Rental Unit
(City)
(State)
(Zip)
Type of Housing Facility:
Describe the # of apartments, # of tenants, etc.
___Room/Apartment in owner’s private residence
______________________________________________________
___Apartment Complex
______________________________________________________
___Single Apartment
______________________________________________________
___House
______________________________________________________
___Double House
___Other (describe)
Construction/Remodeling Information:
What was the date this property was constructed or last remodeled? _________________________
If remodeled, please provide a description of the modifications: __________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Occupancy Information:
One-Person rental?
Yes _____ No _____
Hearing Impaired Equipped
Yes _____ No _____
Suitable for married students?
Yes _____ No _____
Handicapped Accessible?
Yes _____ No _____
Suitable for married students with children?
Yes _____ No _____
Pets allowed?
Yes _____ No _____
Suitable for single parents?
Yes _____ No _____
Rent for one semester? (Popular request!)
Yes _____ No _____
Willing to subsidize with HUD? Yes _____ No _____
Type of parking provided:
Included in rent _____
Permit from landlord_____ Town Permit _____ none _____
Available for move-in: ________________________
Security Deposit & Rent:
Security deposit required?
Yes _____ No _____
Amount of deposit per person? $____________
Total rent per person, per semester
$________
Utilities included in rent/semester?
Yes _____ No _____ Some: ____________________________________
Type of Fire Detection:
9-volt smoke detector
_____
Inter connected and 9-volt _____
9-volt and electric
_____
Inter connected
_____
110-volt smoke detector
_____
Electric
_____
Sprinkler System
_____
Other: ___________________________
Code Office Inspection:
Most recent inspection date and license number by the Town of Bloomsburg’s Code Enforcement Office:
Date _____________________________
License Number __________________________
N/A _______
(only applies to properties within Bloomsburg town limits).
Our office will verify your inspection/license number with the Code Enforcement Office.
It would be helpful if you would include a copy of your lease.
PA Fair Housing Practices:
I, the undersigned, have received a copy of the PA Fair Housing Practices Act and agree to rent my accommodations without
discrimination because of race, color, sex, religious creed, ancestry or national origin, handicap or disability, or use of a guide
dog due to blindness.
Signature of Landlord _____________________________________
Date ___________________
Bloomsburg University of Pennsylvania is committed to providing equal educational and employment opportunities for all
9/2010
persons without regard to race, color, religion, sex, age, national origin, ancestry, life style, sexual orientation, disabilities,
Vietnam era status, or union membership. The university is additionally committed to affirmative action and will take
positive steps to provide such educational and employment opportunities.

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