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COMPLAINT EXHIBIT A

FTC 182-3084

APPLICATION

ADDRESS

PLEASE PROVIDE A VALID PHOTO ID 

Each prospective occupant must complete this application.

Date of Application: ________________ Apartment: ______ 

Monthly Rent: $RENT/month One year lease Term of Lease ____________to ______________ 

Applicant: 

1. Name: _______________________________________________________________________

First Middle Last

Date of Birth: ____________________ Social Security #.: ____________________________________ 

Current Home Address: ____________________________________________________________________ 

Personal Cell Phone #: ___________________________ E-mail: _______________________________ 

Driver’s License Number: __________________________________________________________________ 

Name of Co-Occupant(s), if applicable: _______________________________________________________ 

Current Employer: _______________________________ Telephone No.: _______________________ 

Address: ________________________________________________________________________________ 

Position: _______________________________ Monthly Salary: _______________________________ 

Employment Period: ________________________ Supervisor’s Name: ____________________________ 

Supervisor’s Number: ______________________________ Supervisor’s Email: _____________________ 

Previous Employer: _______________________________ Telephone No.: _______________________ 

Address: ________________________________________________________________________________ 

Position: _______________________________ Monthly Salary: _______________________________ 

Employment Period: ________________________ Supervisor’s Name: ____________________________ 

Supervisor’s Number: ______________________________ Supervisor’s Email: _____________________ 

2. Other income you wish to be considered when this Application is evaluated?

Amount: ____________________________ Source: ___________________________________

3. Bank References:

Checking Account: Bank_____________________ Account #.: ___________________ 

Savings Account: Bank_____________________ Account #.: ___________________ 

4. Motor Vehicles Owned by Applicant:

Year__________ Make____________________ Tag No.__________________ 

Year__________ Make____________________ Tag No.__________________ 
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5. Current Address: __________________________________________________________ 

 Current Rent/Mortgage: _______________ Current Landlord: ________________________ 

 Lease Start Date:_____________________ Lease End Date:__________________________ 

 Landlord Address: ___________________________________________________________ 

Landlord Phone #: _______________________ Landlord Email:______________________ 

 

Previous Address: _________________________________________________________ 

 Previous Rent/Mortgage: _______________ Previous Landlord: ______________________ 

Lease Start Date:_____________________ Lease End Date:__________________________ 

 Landlord Address: ___________________________________________________________ 

Landlord Phone #: _______________________ Landlord Email:______________________ 

6. Personal reference: 

 Name: ________________________ Address: ______________________________ 

 Telephone No: __________________ Relationship: ___________________________ 

7. Do you wish permission to have a pet: Yes _____ No ______ 

 If yes, what type and how many? _________________________________________________ 

Unless specifically agreed to in writing by the Landlord, no pets of any kind will be allowed on the 

Premises. 

8. Have you ever been charged with a criminal offense: Yes _____ No ______ 

Type of Offense (list all offenses): __________________________________________________ 

State(s): _____________ Date of Offense(s):_________________________________________ 

Have you ever been evicted: Yes _____ No ______ Date of Eviction: ___________ 

Have you ever been charged with Failure to Pay Rent: Yes _____ No ______ 

Have you ever been charged with Breach of Lease: Yes _____ No ______ 

Have you ever had wages or property garnished: Yes _____ No ______ 

9. Application Processing Fee: $20.00 via PayPal. If initial portion of application is approved, an additional 

$15 will be paid directly to Experian for processing a credit report. (Instructions will be e-mailed regarding 

how process payment). 

10. Terms and Conditions: 

A. It is understood that the Processing Fee is not refundable. 

B. If the Landlord accepts this Application, either orally or in writing, Applicant(s) will be required 

to enter into a Lease in conformity with this Application on the Landlord’s standard form of Lease 

Agreement (a copy of which has been made available for Applicant(s) to review), and pay a 

security deposit. Until the security deposit is paid and the Lease Agreement is signed by the 

Applicant(s), Landlord shall not be obligated to lease the Property to Applicant(s). 

 
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AUTHORIZATION, AGREEMENT & RELEASE CONSENT FORM

 The Applicant hereby affirms that the answers to the foregoing questions are true and correct and that the 

Applicant has not knowingly withheld any fact or circumstance which would, if disclosed, affect the Application 

unfavorably. The Applicant authorizes Staffordshire Property Management to secure, or secure from a consumer 

reporting agency, an investigative consumer report. This report may contain, but would not be limited to, consumer 

credit, rental history, driving records, employment information, and verification of the Applicant’s residences, 

personal identity, and income. It is understood and agreed upon in full by the Applicant and Staffordshire Property 

Management that this Application & Release is not a contract or proposed contract for the sale or lease of consumer 

goods or services, but solely a release agreement. The Applicant further authorizes Staffordshire Property 

Management and/or a consumer reporting agency to verify any and all information contained in this application and 

to inquire into the character, general reputation, personal characteristics and mode of living of the Applicant, and the 

Applicant hereby releases all concerns from any liability in connection with the information the Applicant gives. 

The Applicant also been advised of the right, under the Federal Fair Credit Reporting Act, Section 606(B) to make a 

written request of Staffordshire Property Management and the consumer reporting agency, within a reasonable time, 

for a complete and accurate disclosure of the nature and scope of the investigation. The Applicant consents, whether 

approved or not approved, to hold and maintain the terms, conditions, and communications related to Staffordshire 

Property Management, this application, and application process in strict confidence, and specifically agrees not to 

disparage Staffordshire Property Management, and any of its employees, managers, or agents in any way, and also 

agrees not to communicate, publish, characterize, publicize or disseminate, in any manner, any terms, conditions, 

opinions and communications related to Staffordshire Property Management, this application, or the application 

process. Staffordshire Property Management also agrees to hold the details of any investigative report and 

background history examination in strict confidence and agrees to only share such details with the owner(s) of the 

property for which the Applicant has applied. Any breach of such confidentiality will support a cause of action and 

will entitle Staffordshire Property Management to recover any and all damages from such a breach. The Applicant 

also consents to, and authorizes the use of, any subsequent consumer report(s) under this authorization in connection 

with the collection of any debt associated with the rental of the residence for which this application was made. 

Finally, the Applicant acknowledges receipt of the summary of consumer rights required by Section 609 of the Fair 

Credit Reporting Act entitled “A Summary of Your Rights under the Fair Credit Reporting Act.” 

 

 I have fully read and understand all of the provisions of this Application & Release and acknowledge 

receipt of a completed copy of same. 

 

_____________________________ __________ _______________________________(SEAL) 

PRINT APPLICANT NAME DATE APPLICANT SIGNATURE 

 

_______________ _________ _______________________________(SEAL) 

APPROVE/REJECT DATE STAFFORDSHIRE PROPERTY MANAGEMENT