Requested Move in Date

MM

DD

YYYY

Applicant Name *

First Name

Last Name

Real Estate Agent (if using)

First Name

Last Name

Real Estate Agent Phone

(###)

###

####

Your Phone *

(###)

###

####

Your Birth Date *

MM

DD

YYYY

CURRENT ADDRESS *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

EMERGENCY Contact Phone

(###)

###

####

CURRENT LANDLORD *

First Name

Last Name

CURRENT LANDLORD Phone *

(###)

###

####

PREVIOUS ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PREVIOUS LANDLORD

First Name

Last Name

PREVIOUS LANDLORD Phone

(###)

###

####

EMPLOYER Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Start Date *

MM

DD

YYYY

Employment *

Full Time

Part Time

Supervisor Name *

First Name

Last Name

Supervisor Phone *

(###)

###

####

ELECTRONIC SIGNATURE: By signing/typing my name below, checking "I Accept" and submitting this form, I authorize Safe Harbor Realty to retrieve my credit report, criminal and eviction records, landlord and employment history. I authorize this form to be shared with the property owner or management company. The property owner or management company solely reviews, accepts or rejects all applications. Safe Harbor Realty cannot be held responsible for any lease terms agreed upon between landlord and tenant or any errors or omissions on the lease. *

I Accept

Today's Date *

MM

DD

YYYY

Safe Harbor Realty does not discriminate in the sale and rental of housing on the basis of race, color, sex, age, religion, disability, national origin, ancestry, sexual orientation, transgender status, martial status, parental status, military discharge, source of income or any protected class