PRINCE SCOTT REALTY

620 CLINTON AVE BRIDGEPORT CT 06605 Phone: 203 722­0016, FAX: 203 696­.0118

OCCUPATION:
PRESENT OCCUPATION
PRIOR OCCUPATION
CO­TENANT'S OCCUPATION
EMPLOYER
SELF­EMPLOYED, D.B.A.
BUSINESS ADDRESS
POSITION HELD
Phone
How Long
NAME AND TITLE OF SUPERIOR
TYPE OF BUSINESS
MONTHLY GROSS INCOME

REFERENCES

PLEASE LIST AND INDICATE ALL SAVINGS (S) AND CHECKING (CK) ACCOUNTS

BANK NAME & BRANCH
ACCOUNT#
BALANCE
DATE OPENED
BANK PHONE

CREDIT BALANCES & OUTSTANDING LOANS

CREDITOR
ACCOUNT#
BALANCE Owned
DATE OPENED

I UNDERSTAND AND AGREE THAT SECURITY, 1ST MONTH’S RENT AND BROKER’S FEES MUST BE POSTED PRIOR TO THE EXECUTION OF A LEASE AGREEMENT IN CERTIFIED FUNDS, MONEY ORDER OR CASH.

I HEREBY DEPOSIT THE SUM OF $.00_ WITH THE LANDLORD/AGENT TO SECURE THE ABOVE PREMISES TO RENT, PENDING EXECUTION OF A LEASE AGREEMENT. I UNDERSTAND THAT MY DEPOSIT MAY BE APPLIED TOWARD ANY RENT LOSS OR OTHER EXPENSES THE LANDLORD/AGENT MAY INCUR AS A RESULT OF MY FAILURE TO FULFILL MY PROMISE TO RENT THE ABOVE NAMED PREMISES BY SIGNING A LEASE AGREEMENT NO LATER THAN TO OCCUPY BY . LEASE TERM:

LANDLORD/AGENT AGREES THAT THE DEPOSIT IS REFUNDABLE IF THE ABOVE APPLICANT IS NOT APPROVED, PROVIDING THAT THIS APPLICATION HAS BEEN FILLED OUT COMPLETELY AND TRUTHFULLY.

HAVE YOU OWNED A HOME IN THE PAST? . IF YES, HOW LONG?. HOW MANY? .

HAVE YOU EVER FILED A PETITION FOR BANKRUPTCY? IF YES, WHEN?.

HAVE YOU EVER BEEN EVICTED FROM ANY TENANCY? .

HAVE YOU EVER WILLFULLY AND INTENTIONALLY REFUSED TO PAY RENT WHEN DUE?.

I HEREBY AUTHORIZE LANDLORD/AGENT TO VERIFY THE VALIDITY OF ALL THE ABOVE INFORMATION, AND TO INQUIRE WITH MY EMPLOYERS, FINANCIAL INSTITUTIONS, AND ANY OF THE CREDIT REPORTING BUREAUS AVAILABLE TO HIM. I AGREE TO SUPPLY ANY ADDITIONAL INFORMATION NEEDED BY OWNER/AGENT TO PROCESS THIS APPLICATION AND I ACKNOWLEDGE THAT MY DEPOSIT WILL BE FORFEIT IF I DO NOT COMPLY WITH ANY SUCH REQUEST. I AGREE THAT MY SCREENING FEE OF $ per adult applicant_ IS NON­REFUNDABLE.

I HEREBY ACKNOWLEDGE RECEIPT OF A COPY OF THIS APPLICATION AGREEMENT. I AGREE THAT LANDLORD MAY TERMINATE ANY AGREEMENT ENTERED INTO IN RELIANCE ON ANY MISSTATEMENT MADE ABOVE. I DECLARE, UNDER PENALTY OF PERJURY, ALL OF THE ABOVE INFORMATION TO BE TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE.