, 2010

DIXIELANDS GLORY, LLC

PHONE 931-589-3370

Today's Date:___________________ Desired Occupancy Date:_______________ Desired Rental Price:___________

Desired Unit Type:______________________________________________________________________
Applicant's Personal Information:
First Name:_________________________ Last _________ ___________________ Birth Date:_______________
Phone# Home: (_____ ) _________________ work #:( _____)__________________. Cell: (_____)_____________
Social Security #: _____________________ Drivers License:___________________
E-mail:______________________________________ .
Car Make Model: ______________________________________. License #: ________________________________.
Car Make Model: ______________________________________. License #: ________________________________.
Car Make Model:______________________________________ . License #: ________________________________.
Additional Occupants (List every occupant's name and their relationship below, including children)
Name:___________________________ Relationship:___________ Age:_______ Cell Phone: ________________
Name:___________________________ Relationship:___________ Age:_______ Cell Phone: _________________
Name:___________________________ Relationship:___________ Age:_______ Cell Phone: ________________
Name:___________________________ Relationship:___________ Age:_______ Cell Phone: _________________
Name:___________________________ Relationship:___________ Age:_______ Cell Phone: ________________
Name:___________________________ Relationship:___________ Age:_______ Cell Phone: _________________

Pets

Breed: _________________ Age: ______ M ___ F____

Breed: _________________ Age: ______ M ___ F____

Method of payment: Cashiers Check ________, Money order_______, Cash _________

Are you able to handle all the minor maintenance/upkeep of the property? Yes___ No___

, 2010

DIXIELANDS GLORY, LLC

PHONE 931-589-3370

Do you have renter's insurance? _____

Have you ever broken a lease? _______________
Have you ever refused to pay rent for any reason? __________
Have you ever been evicted or asked to leave a rental unit? _________
Ever filed for bankruptcy? _____________________
Ever been convicted of a crime? ______________________________________________________________
Will you give us permission to do a criminal background check? _____________________________________
Do you currently have any utilities in your name? ________________________________________________
Do you currently have phone service in your name? _______________________________________________
Is there anything to prevent you from placing utilities or phone in your name? _________________________
Do you know of anything or any reason which may interrupt your ability to pay rent? _________________
RESIDENCE HISTORY
Present Residence Address: __________________________________________________________________
City: _______________________ State: _______ ZIP:_______________
Dates lived at this address? ___________________________________Own: ______ Rent: _____ Occupy:_____
Current phone: ____________________
Name of present landlord/owner/mortgage company: ___________________________________________
Address of present landlord/mortgage company: ______________________________________________
Landlord's phone: ______________________________Monthly payment: ___________________________
Reason for moving:_________________________________________________________________________
Is your rent/mortgage current? ___________________ Number of late payments: ____________________
Security deposit amount currently held by landlord? _____________________________

, 2010

DIXIELANDS GLORY, LLC

PHONE 931-589-3370

Previous Residence Address: ____________________________________________________________________

Previous landlord: _______________________________________ Phone: _______________________________
Dates at this address: ___________________________Reason for moving? ________________________________
Was your full security deposit returned? _____________ # of late payments? _____ Monthly payment? ________
Previous Residence Address:_______ __________________________________________________________
Previous landlord: ______________________________ Phone: _______________________________________
Dates at this address: ______________________________Reason for moving?______________________________
Was your full security deposit returned? ______# of late payments? ________ Monthly payment? _____________
Income History
Applicant's current employment status (check one):
[ ] Full-time [ ] Part-time (less than 32 hrs.) [ ] Student [ ] Retired [ ] Self-Employed [ ] Unemployed
{Government [ ]SSI [ ] SS [ ]Disability [ ] Section 8 [ ] Other House program } [ ] Other_____________________
Applicant employed by: _______________________________________________________________________
Supervisor's name: _______________________________________ average weekly hours: ______________
How long at the place of employment? _________________________________________
Address: _________________________________________________________________________________
Phone: ________________________ Position: _________________________________ Salary: _______________
Please indicate [ ] weekly, [ ] biweekly, [ ] monthly, [ ] or annual average take home: ___________________
Additional Employment_______________________________________________________________________
Average weekly hours: ____________ How long at the place of employment? ____
Address: _____________________________________________________________________
Phone: _____________________________ Position: ______________________________ Salary: _______________
Please indicate weekly, biweekly,

monthly,

or annual average take home:___________________________

, 2010

DIXIELANDS GLORY, LLC

PHONE 931-589-3370

Additional Income/Payment Information

_________________________________________________________________________________________
In the event of some emergency that would prevent you from paying rent when due, is there a relative, person, or
agency that could assist you with rent payments?_____________________

1st Emergency Contact:

Name: ______________________________________Relationship:_______________________________________
Address: ________________________________________________________________________________
Phone Number:________________________ Secondary Phone Number:___________________________________
2nd Emergency Contact:
Name: ______________________________________Relationship:_______________________________________
Address: _______________________________________________________________________________
Phone Number:_________________________ Secondary Phone Number:_________________________________
Do you currently have a savings account, line of credit, or charge card sufficient to cover one month's rent? _______
Additional Income: (optional) If there are additional, verifiable sources of income you would like considered, please
list income source (e.g., self- employment, social security, benefit payments), and requested information below
regarding each source. Applicant may be required to produce additional documentation or provide and sign release
statements. Child support, alimony, or separate maintenance need NOT be disclosed unless you desire this
additional income to be considered for qualification.
Additional source______________________________________ Amount: _______________ Per: ________
Contact Person: ___________________________________________________ Phone: _____________________
How long have you been receiving income from this source? ________How long do you expect this income to
continue? ___________ Is there any reason it would stop? ___________________
Additional source____________________________________________ Amount: _______________ per: ________
Contact Person: ___________________________________________ Phone: ___________________________
How long have you been receiving income from this source? __________How long do you expect this income to
continue? __________ Is there any reason it would stop? _________________
Do you have any commercial vehicles, RV, campers, boats or motorcycles? __________________________
4

, 2010

DIXIELANDS GLORY, LLC

PHONE 931-589-3370

Please note, only cars on application are authorized to be on premises.

List any other current monthly expenses?
Hospital payment: ________________________ Health insurance: _____________________________________
Auto insurance: ____________________________ Renter's insurance: ___________________________________
Child care: _________________________________ Tuition: _____________________________________________
Cable TV:__________________________________ Phone: ______________________________________________
Personal reference:
1. Name:_____________________________________________Relationship:___________________________
Address: _____________________________________________________________________________
How long have you known this person?____________________________ Phone: ___________________________
2.

Name:____________________________________________Relationship:___________________________

Address: ________________________________________________________________________________
How long have you known this person?__________________________ Phone: ___________________________
Professional reference (e.g., attorney, accountant):
3. Name:________________________________________________Relationship:___________________________
Address: _______________________________________________________________________________
How long have you known this person?___________________________ Phone: ___________________________
Name of nearest living relative:
Name:_______________________________________________Relationship:___________________________
Address: ______________________________________________________________________________
How long have you known this person?____________________________ Phone: ___________________________

Thank You!

, 2010

DIXIELANDS GLORY, LLC

PHONE 931-589-3370

Thank you for completing an application to rent from us. Please sign below. Please note that a completed
application requires submission of the following, which will be copied and attached to this application:
_____1 Driver's license picture ID. Note: Rentals will not be shown without picture ID.
_____ 2 weeks of most current pay stubs of each income source listed
_____3 If self-employed, most current Schedule C tax return and proof of current income
A fee of $ 30.00 is charged on all rental applicants for the purpose of verifying the information furnished on this
application. By signing below, applicant hereby represents all information on this application is true, complete, and
hereby authorizes annual verification of information, references, and credit history for continual rental
consideration or for collection purposes should that become necessary. This fee is refundable/non refundable/or
only refundable if applicant meets our minimal criteria but is not selected because they were not the first qualified
applicant.

Applicant acknowledges this application will become part of the lease agreement when approved. If any information
is found to be incorrec4 the application will be rejected and any subsequent rental agreement becomes void. False
and misleading statements will be sufficient reason for immediate eviction and loss of security deposit.

Applicant's signature: _________________________________________________________Date: _____________