Premier Medical Housing

Which apartment are you interested in?

Full Legal Name

Phone

Email

Social Security Number

Date of Birth

Drivers License Number

Current Address

Reason for leaving?

Previous Address

Reason for leaving?

Current Employer

Employer Address

Employer Phone

Supervisor

Your Current Position

Monthly Income

Start Date

End Date (Put "Current" if no end date)

Previous Employer

Employer Address

Employer Phone

Supervisor

Your Previous Position

Start Date

End Date

Have you ever been asked to move out or evicted?

Yes
No

Declared Bankruptcy?

Yes
No

Been sued for damage to a Rental Unit?

Yes
No

Broken a rental agreement or lease?

Yes
No

Been sued for non-payment of rent?

Yes
No

Been convicted of a felony?

Yes
No

Been convicted of selling, distributing, or manufacturing of illegal drugs?

Yes
No

Other Source of Income

Other Source of Income Amount

Reference Name 1

Reference Phone 1

Reference Type 1

Friend/Family
Professional/Work
Personal

Reference Name 2

Reference Phone 2

Reference Type 2

Friend/Family
Professional/Work
Personal

Other Resident Name 1

Other Resident Name 2

Other Resident Name 3

Other Resident Name 4

Emergency Contact Name 1

Emergency Contact Phone 1

Relationship to Emergency Contact 1

Emergency Contact Name 2

Emergency Contact Phone 2

Relationship to Emergency Contact 2

Financial Obligation 1

Amount of Financial Obligation 1

Financial Obligation 2

Amount of Financial Obligation 2

Financial Obligation 3

Amount of Financial Obligation 3

Financial Obligation 4

Amount of Financial Obligation 4

Additional Comments

User Agreement

I hereby state and represent that the information in this application is complete and accurate. I understand that in the event a lease is entered into, it may be cancelled by the Landlord if any of the information provided in the application is materially inaccurate or incomplete. I hereby authorize the Landlord or the Landlord's representatives to verify the information on the application. Verification or re-verification of any information contained in the application will be retained by the Landlord. I hereby authorize "Premier Medical Housing" to obtain information about me including, but not limited to, my credit, my tenant history, my check writing history, and court records/or my criminal record, and I hereby authorize and instruct any entity or person contacted by "Premier Medical Housing", the Landlord, or Landlord's agents to release such information to them. 

I HAVE READ AND ACKNOWLEDGE THIS PROCEDURE FOR SUBMITTING AN APPLICATION.