Country Estates Application

Country Estates Senior Housing
Tenant Application

4002 24TH Ave. S.
Grand Forks, ND 58201
Phone: 701-787-7563
Fax: 701-787-7589
Personal Information

First Applicant

First Name
Last Name
Middle Initial
Home Number
Cell Number
Date of Birth
Gender
Male    Female
Driver License
State Issued
Social Security Number
Marital Status
Married    Single    Widowed    Separated    Divorced

Second Applicant

First Name
Last Name
Middle Initial
Home Number
Cell Number
Date of Birth
Gender
Male    Female
Driver License
State Issued
Social Security Number

Vehicles

Make:
Model:
Year:
Plate #:
Make:
Model:
Year:
Plate #:

Criminal Status

Are you or other household member a registered sex offender?
Yes    No
If yes, explain
Do you or other household members have a criminal history?
Yes    No
If yes, explain
Residence History
Please provide at least 3 years of residency information

Current Address

Address
City
State
Zip
Landlord & Phone
Own or Rent
How long?

Previous Address

Address
City
State
Zip
Landlord & Phone
Own or Rent
How long?

Previous Address

Address
City
State
Zip
Landlord & Phone
Own or Rent
How long?
Have you ever rented from Valley Memorial Homes before? If yes, give building name and/or address
Billing Address
Name
Relationship
Address
Home Phone
Work Phone
Cell Phone
Emergency Notification

Primary Contact

Name
Relationship
Address
Home Phone
Work Phone
Cell Phone

Secondary Contact

Name
Relationship
Address
Home Phone
Work Phone
Cell Phone

Tertiary Contact

Name
Relationship
Address
Home Phone
Work Phone
Cell Phone
The undersigned represent(s) that all of the above statements are true and complete and hereby authorize Valley Memorial Homes, its employees and agents to contact and obtain information from any individuals or entities that may have information regarding past residential arrangements of the undersigned. The undersigned hereby indemnify and hold harmless Valley Memorial Homes, its employees and agents and all other individuals or entities contacted by Valley memorial Homes from all causes of action, expenses, losses or damages of any kind arising from or related to any information obtained regarding the undersigned. All persons will be treated fairly and equally without regard to race, color, religion, sex, familial status, handicap or national origin in compliance with the Fair Housing Act. This application is preliminary only and does not obligate Valley Memorial Homes to deliver possession or keys to the premises. No contract will be established between the parties until a lease agreement has been signed by all parties. Valley Memorial Homes reserves the right to refuse rental to persons with a criminal history.
Applicant Signature: _________________________________
Date: _________________________________
Applicant Signature: _________________________________
Date: _________________________________