I, ___________________________________________, hereby apply to lease ____________________

as of _________________at the rent of $ ___________ per month, for a period of one year.

1.  Date of Birth __________  Sex _____  Marital Status _____  S. S. # _________________________

2.  Names of other occupants ____________________________________________________________

3.  Vehicle:  Make  _________  Yr. _____ Color ________ Dr. Lic. # __________Plate # ___________

4.  Present Residence: __________________________________________________________________

     Dates resided From: __________ To: _________  Rent paid $ ________  per month.

     Name of Landlord _________________________     Phone #________________________________

5.  Previous Residence: _________________________________________________________________

     Dates resided From: __________  To: _________ Rent paid $ ________ per month.

     Name of Landlord ____________________________ Phone # ______________________________

6.  Name of Employer or Business _________________________________Phone: ________________

     Net income _______________ per week  Dates employed From: ____________ To: ____________

7.  Do you have a police record ? ______ Charges __________________________________________

8.  List all open credit obligations:

            Name                                      Monthly Payments                            Unpaid Balance

            _______________                  ___________________                      __________________

            _______________                  ___________________                      __________________

            _______________                  ___________________                      __________________

9.  Emergency Contacts: (one parent & one relative or friend)

       Name __________________________                    Address _______________________________

       Relationship ____________________                    Phone # _______________________________

       Name __________________________                    Address _______________________________

       Relationship ____________________                    Phone # _______________________________

Applicant hereby verifies that the statements above are true and authorizes verification of all references listed above.  Applicant agrees to pay a $50.00 application/apartment holding fee to owner if applicant chooses not to lease the apartment.  Applicant agrees there is a $20.00 credit application fee that is non-refundable if a credit report is required. 

We are an equal housing opportunity provider.  We provide rental housing without discrimination on the basis of race, color, religion, sex, physical or mental handicap, familial status, national origin or other protected classes.

Signature of Applicant________________________________________ Date_______________________  

Phone#______________________Cell#_______________________        

 Return completed application with deposit to:

Village Realty  410 Orchard Court Red Lion PA , 17356

 Rec’d. $__________ for __________________ Date _______________ by _______________________

___________I have read and initialed Paragraphs A, B, C, D, E, F, G, H, I ,J               Revised 4/09

                 Please print out the applications, complete and fax to (717) 246-9877.