Would you be interested in being put on the waiting list?

How many bedrooms? 1 2 3

How did you hear about Main Street Realty?

Personal Information

Full Name*

Home Phone*   Work Phone

E-Mail Address*:

Birthdate:

Have you ever been evicted?   If yes, where?

Current Landlord/Mortgage Holder:
Name

Address   Phone Number

Previous Landlord/Mortgage Holder:
Name

Address   Phone Number

Employment/Financial History

Employed by

Position Held

Length of Employment

Gross Projected Income/Salary for the next 12 months $

Employer Address  Phone Number

List all account(s) and financial institution(s).

Financial Institution     Account Number     Balance

Financial Institution     Account Number     Balance

Other Information

List emergency contact name, address, and phone number (other than member of household). RESIDENTS ONLY.

Name     Address     Phone Number     Relationship

Name     Address     Phone Number    Relationship

Cancellation Policy

Cancellation must be provided in writing prior to applicant receiving deposit. Applicant(s) has 24 hours to cancel application following notification of approval for an apartment. ALL APPLICATION FEES/APPLICATION DEPOSITS ARE NON-REFUNDABLE.

Resident Statement

I/we understand that the above information is being collected to determine my/our eligibility for residency. I/we authorize the owner/manager to verify all necessary information provided on this application/certification, and my/our signature is consent to obtain such verifications. I/we further certify that the statements made in this application/certification are true and complete to the best of my/our knowledge and belief. I/we understand that false information/statements are punishable under federal law and will result in termination of residency.

Name*   Date*

For your peace of mind, Main Street Realty utilizes a statistical validated scoring model for future resident screening. Screening includes checks for multi-state sex offenders, criminal history, and terrorism backgrounds.

Main Street Realty does not discriminate based on race, color, national origin, religion, sex, elderliness, familial status, or handicap. We are proud to comply with the Fair Housing Act and other applicable Federal, state, and local anti-discrimination laws. If you feel discriminated against in any way, please contact the president of Main Street Realty at (804) 649-7579.