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Rental Application

Please tell us about yourself (Co-Applicant must complete a separate rental application form)

Name is required

Phone is required

Cell # is required

D/O/B is required

Age is required

Social Security # is required

How Many Pets is required

Kind of Pet is required

Breed is required

Weight is required

Age is required

Total Number of Occupants is required
Names of all other occupants

Name is required

Relationship is required

Age required

Name is required

Relationship is required

Age required

Name is required

Relationship is required

Age required

Name is required

Relationship is required

Age required
Please give us your residence history for the past 3 years (Beginning with the most current)

Current Address is required

Zip Code is required

Month & Year Moved In is required

Monthly Payment $ is required

Phone is required

Owner/Agent is required

Reason for Leaving $ is required

Previous Address (if within 3 years) is required

Month & Year Moved In is required

Monthly Payment $ is required

Phone is required

Owner/Agent is required

Reason for Leaving $ is required

Previous Address (if within 3 years) is required

Month & Year Moved In is required

Monthly Payment $ is required

Phone is required

Owner/Agent is required

Reason for Leaving $ is required
Please give your employment information
Your Status
Job Status is required
Job Status is required
Job Status is required
Job Status is required
Job Status is required

Current Employer is required

Address is required

Phone is required

Date(s) Employed From is required

To is required

Position is required

Supervisor is required

Your Take Home Salary $ is required

Household Take Home Income $ is required

Current Employer is required

Address is required

Phone is required

Date(s) Employed From is required

To is required

Position is required

Supervisor is required

Your Take Home Salary $ is required

Household Take Home Income $ is required

Previous Employer is required

Address is required

Phone is required

Date(s) Employed From is required

To is required

Position is required

Supervisor is required
If you have other sources of income you would list us to consider, please list income, source and person (Bank, Employer, etc.) who we would contact for confirmation. You do NOT have to reveal alimony, child support or spouse's annual income unless you want us to consider it in this application.


Amount $ is required

Source is required

Contact for Confirmation is required
Please check all that apply
Additional Info is required
Additional Info is required
Additional Info is required
Additional Info is required
Additional Info is required
Additional Info is required
Additional Info is required
Please list your bank & personal references

Bank Name is required

City-State-Branch is required

Phone is required

Bank Name is required

City-State-Branch is required

Phone is required

Name is required

Relationship is required

Phone is required

Name is required

Relationship is required

Phone is required

Name is required

Relationship is required

Phone is required
Have you ever (Check all that apply)
Been terminated/evicted or asked to move-out?
Been terminated/evicted or asked to move-out is required
Been terminated/evicted or asked to move-out is required
Broken a Rental Agreement or Lease?
Broken a Rental Agreement or Lease is required
Broken a Rental Agreement or Lease is required
Been convicted of a Felony?
Been convicted of a Felony is required
Been convicted of a Felony is required
Been sued for non-payment of rent?
Been sued for non-payment of rent is required
Been sued for non-payment of rent is required
Declared Bankruptcy?
Declared Bankruptcy is required
Declared Bankruptcy is required
Been sued for damage to property?
Been sued for damage to property is required
Been sued for damage to property is required
Been convicted for illegal use, possession, manufacturing or distribution of a controlled substance?
Been convicted for illegal use, possession, manufacturing or distribution of a controlled substance is required
Been convicted for illegal use, possession, manufacturing or distribution of a controlled substance is required

If yes to any above questions, Explain is required
Vehicle Information

Total Number of Vehicles is required

Make/Model is required

Year is required

Color is required

Plate #/State is required

Make/Model is required

Year is required

Color is required

Plate #/State is required
Emergency Information

In Case of Emergency, Notify is required

Relationship is required

Full Address is required

Home Phone is required

Cell Phone is required
Signature of Applicant
I hereby apply to lease the above described premises for the term and upon the conditions above set forth and agree that the rental is to be payable on the 1st day of each month in advance. As an inducement to the owner of the property and to the agent to accept this application, I warrant that all statements above set forth are true; however, should any statement made above be a misrepresentation or not a true statement of fact the owner or this agent may reject, without stating any reason for so doing.

***The Security Deposit paid is not refundable if this application is approved following verification.***

I RECOGNIZE THAT AS A PART OF YOUR PROCEDURE FOR PROCESSING MY APPLICATION, AN INVESTIGATIVE CONSUMER AND CRIMINAL REPORT MAY BE PREPARED WHEREBY INFORMATION IS OBTAINED THROUGH PERSONAL INTERVIEWS WITH MY NEIGHBORS, FRIENDS, AND OTHERS WITH WHOM I MAY BE ACQUAINTED. THIS INQUIRY INCLUDES INFORMATION AS TO MY CHARACTER, GENERAL REPUTATION, PESONAL CHARACTERISTICS, AND MODE OF LIVING. I UNDERSTAND THAT I MAY HAVE THE RIGHT TO MAKE A WRITTEN REQUEST WITHIN A RESONALBE PERIOD OF TIME TO RECEIVE ADDITIONAL, DETAILED INFORMATION ABOUT THE NATURE AND SCOPE OF THIS INVESTIGATION.

The above information, to the best of my knowledge, is true and correct.


Signature of Applicant is required

Date Signed is required
******Photo ID will be required at a later time******
How did you hear about our property? (Choose One)
How did you hear about our property is required
How did you hear about our property is required
How did you hear about our property is required
How did you hear about our property is required
How did you hear about our property is required
How did you hear about our property is required
How did you hear about our property is required
How did you hear about our property is required
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Contact Us
We look forward to assisting you in your search for a "new" home !

Office: 607-739-3838
Mon.- Fri. 8 AM to 4:30 PM
815 W. Broad Street
P.O. Box 298
Horseheads, NY 14845
Renter's Insurance
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