Mark Keller
Ph: 330-322-1034
Ph: 330-322-1034412 Hickory Rd.
Lawrenceburg, IN 47025
Thank you for your interest in our rental property. Please help us process your application by
providing all of the information below.
Location of desired property___________________________ Date wanted ____________
Applicant's full name ______________________________ SSN _____________________
Present address __________________________________ e-mail____________________
Land Phone_________________________Cell Phone______________________________
Present landlord __________________________________ Phone ___________________
How long have you lived at this address? ______________ Current rent $_______/month
Reason for moving _________________________________________________________
Previous address ___________________________________________________________
Previous landlord__________________________________Phone____________________
How long at previous address? ______________________Previous rent $_______/month Current Employer: _______________________________________How long? _________
Supervisor's Name ________________________________ Phone ___________________
Position Held ______________________ Employer's address ________________________
Income (from this position) $________ / ______ Other Income (Source) $________________
Previous Employer (if at current less than 6 months) ___________________________________
Previous Employer's Phone ___________ Supervisor's Name ________________________
Please List Names of Others Who Will Reside at This Address:
Name ___________________________________ Relationship ______________________
Name ___________________________________ Relationship ______________________
Do you smoke? ________ Do you have pets? __________
Vehicle: Make/Model/Color ________________ Year ________ Tag No __________ State _____
Driver's License Number ___________________________ State _____________________
In case of personal emergency, notify __________________________________________
Relationship ___________________ Phone______________________________________
REFERENCES:
Your Bank _______________________________ Branch____________________________
Permanent Address, Contact Person and Phone #:__________________________________ _________________________________________________________________________
_________________________________________________________________________
I hereby make application to rent this property. My signature certifies that the above information
is true and complete. I authorize Mark A. Keller to check my credit and contact any references
mentioned above.
Applicant's Signature ______________________________________ Date _____________
