Online Application

Rental Address Applying For:

Date:

Personal Data:

Your Name:

Date of Birth:

SS Number:

Current Address:

Current Phone Number:

Your Email Address:

Driver's License Number:

Expiration Date:

Occupants:

Relationships:

Ages:

Car Make, model, year:

Car License Plate Number:

Pets (Yes or No - select one)
 Yes No

Do you have NIPSCO in your name? Yes or No, if not whose name?

Do you have water in your name? Yes or No, if not whose name?

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Employment Info:

Occupation:

Employer’s Name:

Self-employed doing business as:

Business Address:

Business Phone:

Type of Business:

Position held:

Name and title Of Supervisor

HR name & number:

How long have you worked there?

Monthly Gross Income:

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Personal Data - Applicant #2:

Your Name:

Date of Birth:

SS Number:

Current Address:

Current Phone Number:

Your Email Address:

Driver's License Number:

Expiration Date:

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Credit References - Applicant #1:

Bank/Credit Union Name:

Address:

Phone:

Checking Account #:

Savings Account #:

Do you have a loan?

Amount Owed on current loan:

Monthly Payment on current loan:

Purpose of Loan:

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Credit References - Applicant #2:

Bank/Credit Union Name:

Address:

Phone:

Checking Account #:

Savings Account #:

Do you have a loan?

Amount Owed on current loan:

Monthly Payment on current loan:

Purpose of Loan:

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Personal References:

Name:

Address/City/State:

Phone:

How long known:

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Personal References - 2:

Name:

Address/City/State:

Phone:

How long known:

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Personal References - Relative:

Relative Name:

Relative Address/City/State:

Relative Phone:

Relationship to this relative

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Have you ever filed a petition for bankruptcy?
 Yes No

Have you ever been evicted from any tenancy?
 Yes No

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

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