RENTAL OFFICE: (626) 447-3104 FAX: (626) 447-3162 A separate application must be completed for each prospective tenant over 18 years of age.

ADDRESS YOU'RE APPLYING FOR: RENTAL AMOUNT:$
MOVE-IN DATE: YOUR EMAIL:

LAST NAME FIRST NAME MIDDLE NAME

SOCIAL SECURITY NUMBER

DATE OF BIRTH

DRIVER’S LICENSE NUMBER

STATE

HOME OR CELL PHONE NUMBER

1

PRESENT ADDRESS, CITY, STATE, ZIP

DATE IN

DATE OUT

OWNER/MANAGER NAME

OWNER/MANAGER NUMBER

REASON FOR MOVING

COMPLETE SECTIONS 2 AND 3 ONLY IF YOU HAVE LIVED AT ADDRESS 1 LESS THAN FIVE YEARS

2

PREVIOUS ADDRESS, CITY, STATE, ZIP

DATE IN

DATE OUT

OWNER/MANAGER NAME

OWNER/MANAGER NUMBER

REASON FOR MOVING

3

PRIOR ADDRESS, CITY, STATE, ZIP

DATE IN

DATE OUT

OWNER/MANAGER NAME

OWNER/MANAGER NUMBER

REASON FOR MOVING

PROPOSED OCCUPANTS (LIST ALL IN ADDITION TO YOURSELF)

NAME

AGE

NAME

AGE

	A	PRESENT OCCUPATION	EMPLOYER NAME
		HOW LONG WITH THIS EMPLOYER?	EMPLOYER ADDRESS
		NAME OF SUPERVISOR	EMPLOYER PHONE NUMBER
COMPLETE SECTION B IF YOU HAVE BEEN WITH PRESENT EMPLOYER LESS THAN FIVE YEARS	B	PREVIOUS OCCUPATION	EMPLOYER NAME
		HOW LONG WITH THIS EMPLOYER?	EMPLOYER ADDRESS
		NAME OF SUPERVISOR	EMPLOYER PHONE NUMBER

BANK NAME	ADDRESS		ACCOUNT NUMBER	BALANCE
		CHECKING
		SAVINGS

PLEASE LIST ALL CREDIT CARDS AND FINANCIAL OBLIGATIONS:

NAME OF CREDITOR

TOTAL AMOUNT OWED

MONTHLY PAYMENT

NOTE: IF THERE ARE MORE CREDITORS, PLEASE ATTACH AN ADDITIONAL SHEETOF PAPER

IN CASE OF EMERGENCY

ADDRESS

PHONE NUMBER

RELATIONSHIP

AUTOMOBLIE MAKE	MODEL	YEAR	LICENSE NUMBER
AUTOMOBLIE MAKE	MODEL	YEAR	LICENSE NUMBER
OTHER VEHICLE MAKE	MODEL	YEAR	LICENSE NUMBER

CURRENT RENT YOU ARE PAYING $ CURRENT TAKE-HOME PAY PER MONTH $

ANY ITEM LEFT BLANK WILL BE ASSUMED AS A "NO" OR "NONE" ANSWER

HAVE YOU EVER BEEN EVICTED?......................................................................................................................................... Choose Yes No

HAVE YOU EVER RECEIVED A "3-DAY NOTICE TO PAY RENT OR QUIT"?....................................................................... Choose Yes No

HAVE YOU EVER HAD AN ACCOUNT PLACED "IN COLLECTION" FOR FAILURE TO MAKE PAYMENTS?.................... Choose Yes No

HAVE YOU EVER FILED FOR BANKRUPTCY?....................................................................................................................... Choose Yes No

HAVE YOU EVER BEEN ASKED TO MOVE, OR BEEN GIVEN A "30-DAY NOTICE TO MOVE"?........................................ Choose Yes No

HAVE YOU EVER BEEN CONVICTED OF A FELONY (IF YES, DESCRIBE BELOW)?........................................................ Choose Yes No

WILL YOU HAVE WATER FILLED FURNITURE SUCH AS A WATERBED?.......................................................................... Choose Yes No

WILL YOU HAVE ANY PETS (IF YES, DESCRIBE BELOW)?................................................................................................. Choose Yes No

IF YES, PLEASE DESCRIBE:

APPLICANT REPRESENTS THAT ALL OF THE ABOVE STATEMENTS ARE TRUE, ACCURATE, AND COMPLETE, AND HEREBY AUTHORIZES

VERIFICATION OF THE ABOVE ITEMS INCLUDING BUT NOT LIMITED TO THE OBTAINING OF A CREDIT REPORT, AND AGREES TO

FURNISH ADDITIONAL CREDIT REFERENCES ON REQUEST. THIS APPLICATION ISTHE PROPERTY OF THE LANDLORD AND WILL NOT

BE RETURNED TO THE APPLICANT.

DATE: APPLICANT SIGNATURE:

By Dating and Entering your true and correct name in the box above and sending this form electronically shall bear as though the form was completed with your signature.

Copyright 2002 Victory Homes, Inc.