Ansonia Center Rental Application

Applicant Information

Personal Information

First Name

Last Name

DOB(Date of Birth)

SSN Number

License / State ID#

Home Phone

Cell Phone

Email

Type of Pet(s)

How Many ?

Size / Avg.Size if multiple

Rabies Vaccination Number

Desired Apt Size

Apt Number(If Known)

Current Residence

Address

City

State

Zip Code

Renting or Owning

Monthly Payment / Rent

How Long ?

Lease Exp.Date

Landlord 's Name

Landlord Phone Number

Previous Residence

Address

City

State

Zip Code

Owned or Rented

Monthly Payment / Rent

How Long ?

Lease Exp.Date

Landlord 's Name

Landlord Phone Number

Vehicle Information

Type of Vehicle

Make

Model

Year

Color

License Plate#

Employment Information

If retired, please check box.

Current Employer

Employer Address

Length of Employment

Supervisor 's Phone Number

Supervisor 's Email

City

State

Zip Code

Position

Hourly or Salary

Annual Income

Emergency Contact

Name of person not residing with you

Address

City

State

Zip Code

Cell Phone

Relationship

Co - Applicant Details, if applicable

First Name

Last Name

DOB(Date of Birth)

SSN Number

Home Phone

Cell Phone

Current Residence

Address

City

State

Zip Code

Owned or Rented

Monthly Payment / Rent

How Long ?

Previous Residence

Previous Address

City

State

Zip Code

Owned or Rented

Monthly Payment / Rent

How Long ?

Co - Applicant Employment Details

Current Employer

City

State

Zip Code

Employer Address

Length of Employment

Supervisor 's Phone Number

Supervisor 's Email

Position

Hourly or Salary

Annual Income

References

Applicant References

1.

Name

Address

Phone

2.

Name

Address

Phone

Co - Applicant References

1.

Name

Address

Phone

2.

Name

Address

Phone

Acknowledgment

I authorize the verification of the information provided on this form as to my credit and employment.I have received a copy of this application.I recognize that as a part of this application process, Savarino Companies’ representatives and contractors will conduct an investigative consumer report whereby information is obtained through several means including personal interviews with others with whom I may be acquainted, along with a credit check and background check.

I understand that the fee for processing this application will be $20.

I have read and consent with the previous statements.

If you believe you have been the victim of housing discrimination, you may file a complaint with the New York State Division of Human Rights by downloading a complaint form at www.dhr.ny.gov.