Application is hereby made to rent premises generally described as _________________ for a term of __________ and ending the _____ day of __________, 20___, for which monthly rental shall be __________, payable in advance, and for which a security deposit of $ __________ shall be due prior to occupancy of the above-described premises.
A deposit of __________ is made herewith on account of the first month's rent, with the understanding that if this application is accepted and the applicant fails to execute a lease before the beginning date specified above, or to pay the balance due as first month's rent, said payment will be forfeited as liquidated damages. It is also understood that if this application is not accepted, or if the premises are not ready for occupancy by the applicant on the date specified above, said deposit shall be refunded to the applicant forthwith, upon applicant's request.
Name: ________________________ SS #: _______________
The information provided herein may be used by the landlord or his agent to determine whether to accept this application. Upon written request within ____ days, the landlord or his agent will disclose to applicant in writing the nature and scope of any investigation landlord has requested, and will, if this application is refused, state in writing the reason for said refusal.