BEUMER REALTY                                                                                

 Phone: (850) 492-0446                                                                                                                                             FAX: (850) 492-0113

 12510 Gulf Beach Highway                                                                                                                                     Pensacola, FL 32507

 Email: beumer.realty@prodigy.net                                                                                                                  www.beumerrealty.com___________________

                                                             PERSONAL DATA

Name: _________________________________________ Social Security No: ______ -______ - _______

Date of Birth: _______________ Driver’s License No: ______________________ State: ________Exp Date:__________

Present Address: ___________________________________________________________________________________

City/State/Zip: __________________________________________ Hm Phone: _______________ Cell:  _____________

Name of Co-Tenant: ______________________________Social Security No: ______ -_______ -_______

Date of Birth: _______________ Driver’s License No: _______________________ State: ________Exp Date:__________

Present Address: ____________________________________________________________________________________

City/State/Zip: __________________________________________ Hm Phone: ________________ Cell: _____________

Name of Landlord/Agent & Phone ____________________________________________________________________

Other Occupants-Relationship and Ages:  1. ______________________________ 2. ______________________________

3. __________________________________4._______________________________5. ___________________________

Pets:  1. ___________ 2. __________ Breed: 1. ________________ 2. _______________ Weight: 1. _______ 2. _______

Car Make:  1. ___________________ Year: ________ Model: ___________ Color: ____________ License #: __________

                    2. ___________________ Year: ________ Model: ___________ Color : ____________ License #: __________

                                                                  OCCUPATION

Employer/Self-Employed: ___________________________________Title/Rank ______________ How Long: _________

Employer’s Address: ______________________________________________________Work Phone: ________________

Co-Tenant’s Employer: _____________________________________ Title/Rank ______________ How Long: _________

Employer’s Address: ______________________________________________________ Work Phone: _______________

Monthly Gross Income: 1. $_________________ 2. $___________________ Additional Income: $__________________

** IF EMPLOYED OR SELF EMPLOYED LESS THAN TWO YEARS, PLEASE PROVIDE INFORMATION FROM PREVIOUS EMPLOYMENT.

Have you ever filed a petition for bankruptcy? __________ Have you ever been evicted from any tenancy? __________

Have you ever willfully and/or intentionally refused to pay any rent when due? ______________

I DECLARE THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT. I AUTHORIZE ITS VERIFICATION AND THE OBTAINING CONSUMER CREDIT REPORT.

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

Date: ________________________

______________________________________________         ____________________________________________

Applicant’s Signature                                                                         Co-Applicant’s Signature

Property address applying for: __________________________________________________________

Anticipated length of Occupancy: _____________________________________

                                                                       REFERENCES

Bank Reference: __________________________________ Bank Location: ___________________ Phone: ____________

Credit Reference: 1. _________________________________________________________Balance: $________________

2. ________________________________________________________________________ Balance: $_______________

Personal Reference               Address                 City/State              Phone             Length of Acquaintance          Occupation

1. ________________________________________________________________________________________________

2. ________________________________________________________________________________________________

Nearest Relative                                                                 Address                                                               Phone

1. ________________________________________________________________________________________________

2. ________________________________________________________________________________________________

ADDITIONAL EMPLOYMENT/INCOME

Employer: ________________________________________________________________________________________

Employer’s Address: _______________________________________________ Work Phone ______________________

Additional Income: $__________________