Madison's Derr Apartments

(*) Indicates Required Field

Please Select an Apartment to apply for:	Please enter a move in date:
*	* (eg. 1/1/2008)

Applicant Information

First Name:	*	Last Name:	*
E-Mail:	*	Phone Number:	*
Birth Date:	/ / *

Current Address

Street Address:	*	Apt: (if applicable)
City:	*
State:	* Zip: *

From:

* / *

To:

/ *

Total Rent/Month $:	*
Landlord Name:	*	Landlord Phone Number:*
Reason for Moving:	*

Previous Address

Street Address:	*	Apt: (if applicable)
City:	*
State:	* Zip: *

From:

* / *

To:

/ *

Total Rent/Month $:	*
Landlord Name:	*	Landlord Phone Number:*
Reason for Moving:	*

Employment History

Current Employer

Employer:		Job Title:
Supervisor:		How Long:
Montly Gross Salary:		Phone Number:

Previous Employer

Employer:		Job Title:
Supervisor:		How Long:
Montly Gross Salary:		Phone Number:

If you are a student Please List Your School:
If so, what is your expected graduation date:

Credit Information

Bank: Bank Address: Bank Phone Number:

General Information

Have you or your spouse ever been evicted?	YesNo
Have you or your spouse ever been convicted of a felony?	YesNo
Have you or your spouse ever filed for bankruptcy?	YesNo
Will this unit be your only place of residence?	YesNo

Automobile Information

Year: Make: Model:


Licence Plate #:		State:

Driver's Licence #:		Driver's Licence State:

Emergency Contact Information

Name:
Street Address:		Apt: (if applicable)
City:
State:	Zip:
phone:

Terms And Agreements

Upon acceptance of the application and at the time of signing of the lease, the applicant agrees to pay the security deposit in full. If after signing the lease, applicant fails to honor lease agreement, they will be held liable for any and all damager caused by the breach of the contracted agreement.

Applicant understands loud parties; noisy guests or loud music may disturb other residents and are not permitted in the building. Tenants are responsible for guest's actions while in or around the building. Failure to abide by these firm rules will result in immediate notification requiring corrective action or an eviction notice to vacate.

NO PETS ARE ALLOWED IN THE APARTMENT AT ANY TIME!!

Certification:

I hereby certify that, to the best of my knowledge, after due inquiry, all of the information contained in this rental application is true and complete. I understand that if Te Derr Apartments selects me as a tenant, they may terminate my lease immediately if it is learned that any of the information contained in this rental application is false.

I hereby authorize The Derr Apartments and its agents to thoroughly investigate and verify all of the statements contained in this rental application. I understand that The Derr Apartments may perform an investigative report to determine my character, general reputation, personal characteristics and mode of living, and hereby authorize The Derr Apartments to contact my references listed on this rental application with respect to me or any of the individuals listed as part of my household.

I hereby release and hold harmless The Derr Apartments and its agents from and against any and all actions, claims, costs, damages, expenses, liabilities, losses and suits arising out of or resulting from The Derr Apartments obtaining this information described above.

Signature: *

Monday, February 6, 2012, 1:41 pm