Date

Unit interests:
Rental unit applying for: Walnut Street dwelling High Street dwelling
Number of bedrooms: Name of unit:

Contact & Bio Information:

I am not a US Citizen. I am a US Citizen.
If you are not a US Citizen, what country are you from?

Length of time at current residence:

Reason for leaving current residence:

Length of time at employer:

Parent's information:

Reference(s)

rental roomate information:

NAME(S) AND RELATIONSHIP OF ALL WHO WILL OCCUPY THE PREMISES:

Emergency contact information:

HAVE YOU EVER BEEN EVICTED?: Yes No
HAVE YOU EVER REFUSED TO PAY ANY RENT WHEN DUE?: Yes No
If so why?

A DEPOSIT EQUAL TO ONE MONTH’S RENT MUST ACCOMPANY THIS APPLICATION. IF THE APPLICATION IS APPROVED, THE DEPOSIT WILL BE CONVERTED TO A SECURITY DEPOSIT. IF THE APPLICATION IS NOT APPROVED, THE DEPOSIT WILL BE RETURNED.

BY CHECKING THE BOX I DECLARE THE FOREGOING TO BE TRUE AND AGREE THAT JOHN P KUEHN AND NATALIE C. KUEHN OR THERE AGENTS MAY RELY UPON THIS INFORMATION WHEN ENTERING INTO AN AGREEMENT WITH ME.