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Online Application

Property will be shown and made available to all persons without regard to race, color, creed, religion, national origin, sex, familial status, handicap, or elderliness in compliance with all applicable federal and state and local fair housing laws and regulations.

The Applicant named below hereby makes application to Matchbox Realty & Management Services, Inc. (Management) as managing agent for the owner of the property located in the City of Harrisonburg, Rockingham County, City of Staunton or Augusta County, Virginia and described as:
.

A nonrefundable application fee of $30.00 shall accompany this application.

Please complete the entire application - If a field does not apply to you please type N/A

How did you find out about Matchbox Realty/OffCampusHousing.com/HarrisonburgHousing.com?

Personal Information
First Name	Last Name	Social Security #
Date of Birth	Local/Cell Phone #	Home Phone #
Email Address
Current/Home Address
City	State	Zip
Landlord	Landlord Phone	Rent
Previous Address
City	State	Zip
Previous Landlord	Previous Landlord Phone	Previous Rent
Auto Make	License Plate	Year In School

Employer Information
Employer
Employer Address
City	State	Zip
Position	Supervisor	Monthly Income
Date Started
Other Occupants
Name	Age	Relationship
Name	Age	Relationship
Name	Age	Relationship

Emergency Contact Information
In Case of Emergency, Notify:	Relationship to Applicant	Phone Number
Emergency Contact Address
City	State	Zip

Parent/Guardian Information
Parent/Guardian Name 1	Parent/Guardian Name 2
Parent/Guardian Address
City	State	Zip
Home Phone #	Work Phone #	Email Address
Employer	Position

Other Information
Are you in the Military? Yes No	If yes, Branch	Rank
Duty Station	Commanding Officer

Have you ever been convicted of a felony? Yes No	Have you ever filed a petition in bankruptcy? Yes No
Has a judgement ever been entered against you? Yes No	Is a smoke detector for the hearing impaired required? Yes No
If any of the above were answered YES, please explain:

Disclosure of Brokerage Relationship

Real Estate licensees in Virginia who have entered into brokerage relationships are required by law to make prompt written disclosure of those brokerage relationships to those they work with, but do not represent in the real estate transaction. The undersigned do hereby acknowledge that Matchbox Realty & Management Services, Inc. represents the Owner in this transaction.

Applicant should exercise whatever due diligence applicant deems necessary with respect to information on any sexual offenders registered under Chapter 23 (sec. 19.2 – 387 et seq.) of Title 19. Such information may be obtained by contacting your local police department or the Department of State Police, Central Records Exchange at (804-674-2000).

The Applicant hereby certifies that the information contained in this Application is true and correct to the best of Applicant’s knowledge and belief. Applicant hereby authorizes Management to conduct a credit check on Applicant and an appropriate background check to verify information provided herein by Applicant for approval or rejection of this Application.

I have read and understand the terms and conditions of this Application for Lease. This application is separate from any lease agreement.

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Online Application

Personal Information

Employer Information

Other Occupants

Emergency Contact Information

Parent/Guardian Information

Other Information

Disclosure of Brokerage Relationship