APPLICATION TO RENT/SCREENING FEE

(C.A.R. Form LRA, Revised 4/03)

I. APPLICATION TO RENT

THIS SECTION TO BE COMPLETED BY APPLICANT. A SEPARATE APPLICATION TO RENT IS REQUIRED FOR EACH
OCCUPANT 18 YEARS OF AGE OR OVER, OR AN EMANCIPATED MINOR.

Applicant is completing Application as a (check one) ✘ tenant, tenant with co-tenant(s) or guarantor/co-signor.
Total number of applicants__________________________________________________________________________________
PREMISES INFORMATION

Application to rent property at____________________________________________ (“Premises”)

Rent: $___________ per ________ Proposed move-in date___________________
PERSONAL INFORMATION
FULL NAME OF APPLICANT _________________________________________________________
Social Security No ________________ Drivers License No. __________________ State ______ Expires_______
Phone number: Home___________________ Work ___________________ Other ____________________________
Email________________________________________________________________________________________________
Name(s) of all other proposed occupant(s) and relationship to applicant __________________________________________
_____________________________________________________________________________________________________
Pets or service animal (number and type) ___________________________________________________________________
Auto: Make _________ Model ________ Year ________ License No. ________ State ___ Color_________
Other vehicle(s): _______________________________________________________________________________________
In case of emergency, person to notify___________________________ Relationship___________________________
Address ___________________________________ Phone ________________________________________________
Does applicant or any proposed occupant plan to use liquid filled furniture? ✘ No Yes Type
Has applicant been a party to an unlawful detainer action or filed bankruptcy within the last seven years? No
If yes, explain _________________________________________________________________________________________
Has applicant or any proposed occupant ever been convicted of or pleaded no contest to a felony? No Yes
If yes, explain _________________________________________________________________________________________
Has applicant or any proposed occupant ever been asked to move out of a residence? No Yes
If yes, explain _________________________________________________________________________________________
RESIDENCE HISTORY
Current address ____________________________________ City/State/Zip ______________________________________
From ___________________ to _______________________ Name of Landlord/Manager ___________________________
Landlord/Manager’s phone ____________________________ Do you own this property? No Yes
Reason for leaving current address _______________________________________________________________________
Previous address ____________________________________ City/State/Zip ______________________________________
From ___________________ to _______________________ Name of Landlord/Manager ___________________________
Landlord/Manager’s phone ____________________________ Do you own this property? No Yes
Reason for leaving current address _______________________________________________________________________
EMPLOYMENT AND INCOME HISTORY
Current employer_______________________________ Supervisor _______________________ From _______ to ________
Employer’s address __________________________________________________ Supervisor’s Phone ___________________
Position or title _________________________________ Phone number to verify employment _________________________
Employment Gross Income $ _____________ per _____ Other $ ____________ per ________ Source __________________
Previous Employer _______________________________ Supervisor ____________________ From _______ To __________
Employer’s address ___________________________________________________ Supervisor’s phone __________________
Position or title __________________________________ Employment Gross Income $ ___________ per ________________
(PAGE 1 of 2) APPLICATION TO RENT/SCREENING FEE Applicant’s initials (____) (_______)

Agent: George Lange Phone: (818)297-7664 Fax: (818)338-1100 Lic# 01773119

Broker: Century 21 Adobe Realty 5683 Kanan Road, Agoura Hills, CA 9130

Property Address: _____________________________________________________ Date _____________

 CREDIT INFORMATION
Name of creditor Account number Monthly payment Balance Due
_______________________________________ _______________ _______________ _____________
_______________________________________ _______________ _______________ _____________

Name of bank/branch Account number Type of Account Account Balan

_______________________________________ _______________ _______________ _____________
_______________________________________ _______________ _______________ _____________

Name _____________________________
Phone _____________________________
Name _____________________________
Phone _____________________________
PERSONAL REFERENCES
Address _________________________________________________________
Length of acquaintance ___________________ Occupation ________________
Address _________________________________________________________
Length of acquaintance _____________________________________________

Name _____________________________
Phone _____________________________
Name _____________________________
Phone _____________________________
NEAREST RELATIVES
Address _________________________________________________________
Length of acquaintance ___________________ Occupation ________________
Address _________________________________________________________
Length of acquaintance _____________________________________________

Applicant understands and agrees: (i) this is an application to rent only and does not guarantee that
applicant will be offered the Premises; and (ii) Landlord or Manager or Agent may accept more than one
application for the Premises and, using their sole discretion, will select the best qualified applicant.

Applicant represents the above information to be true and complete, and hereby authorizes Landlord or
Manager or Agent to : (i) verify the information provided; and (ii) obtain credit report on applicant.

If application is not fully completed, or received without the screening fee: (i) the applicant will
not be processed, and (ii) the application and any screening fee will be returned.

X Applicant signature___________________________ Date _________________ Time_____________

I ___________________ authorize either Listing Agent or Seller Agent to process my credit report
($30)

I will provide my own credit report (less than 3 months old)

X Applicant signature __________________________ Date __________________ Time _____________

(PAGE 2 of 2) APPLICATION TO RENT/SCREENING FEE

Agent: George Lange Phone: (818)297-7664 Fax: (818)338-1100 Lic# 01773119

Broker: Century 21 Adobe Realty 5683 Kanan Road, Agoura Hills,
CA 91301