LEASE PURCHASE APPLICATION FOR CLOGGER PROPERTIES, LLC

PERSONAL INFORMATION

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  1. Please provide the following contact information:

    First Name
    Last Name
    Middle Initial
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Work Phone
    Home Phone
    FAX
    E-mail

  2. Social Security Number

  3. Enter your Place of Birth

  4. Enter your Date of Birth (mm/dd/yy)

  5. Enter your Driver License Number

  6. Enter your DL State

  7. Enter your DL expiration date

  8. How long at present address

  9. Present Landlord Name

  10. Present Landlord Phone Number

  11. Current Monthly Rent or Mortgage Payment

  12. Rent or Mortgage Paid Through

  13. Current Lease Expires

  14. Enter your Previous Address

  15. How long did you live at your Previous Address

  16. Enter your Previous Address Landlord's Name

  17. Enter your Previous Address Landlord's phone

  18. List all people who will occupy
    List their relationship to you and their age

  19. Enter your Pet's name and type

  20. Enter your car make, year, model, color, license #

  21. Enter your present occupation

  22. Enter your Employer's Name

  23. Business Address

  24. Business Phone

  25. Name and title of Supervisor

  26. How long have you worked there

  27. Monthly Gross Income

  28. Enter your Prior Occupation

  29. Previous Employer

  30. Previous Employer's address

  31. Previous Employer's name

  32. Previous Employer's phone

  33. How long did you work for them?

  34. Personal Reference #1 Name

  35. Personal Reference #1 Phone #

  36. Personal Reference #2 Name

  37. Personal Reference #2 Phone #

  38. Personal Reference #3 Name

  39. Personal Reference #3 Phone

  40. Personal Reference #4 Name

  41. Personal Reference #4 Phone

  42. Name of nearest relative, their phone number, and relationship to you.

  43. Name of an emergency contact person, their phone number, and relationship to you.

  44. Have you ever filed a petition for bankruptcy?

  45. Type of bankruptcy and date of discharge

  46. Have you ever been evicted from an tenancy?

  47. Have you ever been found liable in a civil suit?

  48. Have you ever been found guilty in a criminal matter, other than minor traffic violations?

  49. Have you ever willfully and intentionally refused to pay any rent when due?

  50. I DECLARE THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT.  I AUTHORIZE SELLER OR THIRD PARTY OF SELLER'S CHOOSING, TO OBTAIN EMPLOYMENT VERIFICATION, RENT/MORTGAGE VERIFICATION, CREDIT REPORT (to include the sharing or discussing of credit report with third party of seller's choosing), AND VERIFICATION OF ANY OTHER INFORMATION DEEMED NECESSARY BY SELLER TO CONFIRM INFORMATION STATED ABOVE AND TO APPROVE THIS APPLICATION.

    I agree that Seller may terminate any agreement entered into in reliance on any misstatement made above.

    By entering your name below and entering today's date, you agree that it is the same as your regular signature

Author information goes here.
Copyright © 2003 [OrganizationName]. All rights reserved.
Revised: 12/12/09