Prospective Tenant Background Check Consent Form - City Of Dubuque
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1City of Dubuque
Prospective Tenant Background Check Consent Form
Email to: or Fax to: 563-587-3849
Last Name
First Name
Middle Name
Any Other Names Used
Phone Number(s)
Date of Birth
Biological Sex
Gender Identity
Social Security Number
Current Address:
Three (3) Prior Addresses (Include City, State, Zip)
1.
2.
3.
► Additional household members eighteen (18) years or older: (Name, Date of Birth)
(Additional household members eighteen (18) years or older must also complete a Prospective Tenant Background Check Consent Form)
1.
3.
2.
4.
Number of household members under eighteen (18) years of age:
Have you been convicted of a felony or a serious or aggravated misdemeanor in the past five (5) years?
I hereby consent to the use of the above information to search my criminal history records. I am of legal age and sign this as
my own free act and deed. I understand what this document means and what I am agreeing to by signing it.
Signature
Date
DISCLAIMER: This information is being provided at the request of Landlord, and in accordance with the written instructions of the individual to whom it
relates, and Landlord agrees that the decision to rent is Landlord's SOLE decision. The city of Dubuque is not an agent of Landlord nor does it guarantee or
warrant the character or suitability of a tenant. The city is simply providing information requested.
To be Completed by Landlord
RESULTS
Property Agent
Name of Property
Property Address (Include Apt. #)
#of Bedrooms
Fax / Email
Phone #
Date
For Internal Use by City Only
Form Received by:
Date:
Check Completed by:
Date:
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