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Section 1 - About You:
Select the type of accomodations you are interested in:
Please select one or more of the following:
Furnished Unfurnished
Short-term lease (< 12 mos) 2 months or longer
House Apartment
When are you looking to move?
As soon as possible
Next month
Flexible (any time over the next few months)
Other (please specify): 
Full Name (exactly as it appears on driver's license or gov't ID card: First:    Middle:   Last: 
Your E-mail address:
Former last names (maiden and married)
Home Phone #
Cell Phone #:
Work #
Your Social Security #:
Driver's license # and state:
Birth Date:
Sex:
Marital Status: Single Married Divorced
Widowed Separated  
Current address where you live:
Monthly rent: (specify utilities included)
Current owner or manager's name:
Their phone: Date moved in:
Why are you leaving your present residence?
Your previous home address (street/city/state/zip):
Name of above owner or manager:
Their phone: Previous monthly rent:
Date moved in: Date you moved out:
Names and ages of children/occupants that will occupy apartment with you:
Section 2 - Your Work:
Present employer:
Employer address (street/city/state/zip):
Work phone:
Position:
Your gross monthly income is:
Date you began this job:
Supervisor's name and phone:
Previous employer:
Position:
Gross monthly income was:
Dates job began and ended:
List any other income:
List all regular monthly payments: (car payments, phone bills, credit cards, insurance, utilities, medical, etc)
Car Payment: Credit Cards:
Child Support: Alimony:
Car Insurance: Other Insurance:
Mobile Phone: Home Phone:
Other Payments:  
Section 3 - Your Rental History:
Have you, your spouse, or any occupants listed above ever (check any that apply):
Been evicted or asked to move out?
Broken a rental agreement or lease contract?
Declared bankruptcy?
Been sued for nonpayment of rent?
Been sued for damage to rental property?
If you checked any of the above items, please provide a brief explanation here:
Have you, your spouse, or any occupants listed above ever (check any that apply):
Ever been convicted of a felony?
Received deferred adjudication for a felony?
If you checked either of the above items, please provide a brief explanation here:
Your Vehicles
(list all vehicles to be parked by you)
Make and color of vehicle:
Year: License: State:
Make and color of vehicle:
Year: License: State:
Emergency
(Emergency contact person over 18, who will not be living with you)
Name:
Address (street/city/state/zip):
Work phone:
Home phone:
Relationship:
Authorization

Checking this box represents your legal signature of acceptance of the following statement:

I authorize Mill City Properties to verify the above information by all available means. Owner is not required to reverify or investigate preliminary findings.


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295 Dutton St., Suite 2, Lowell, MA. 01852 | ph: (978) 937-2000 | fx: (978) 455-3317 |

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