DATE

Full Name

Email Address

Date of Birth

Status

Single

Married

Solo

Defacto

Please state who else will be residing with you

Name

Relationship

Age

Name

Relationship

Age

Name

Relationship

Age

Are you, or any of the above stated smokers?

Yes No

Your current address

Your Contact phone numbers

HOME

WORK

MOB

Previous Address

Your Occupation

Currently employed with

Are you a beneficiary

Yes No

Benefit case Manager

Benefit Number

Why do you need to vacate your present address?

Do you have rental references?

Yes No

What type of accomodation do you require? (eg. House, Flat? No of Bedrooms? Garage?)

Maximum rent you can afford

$

When do you need a place by?

Have you any pets?

Yes No

Drivers Licence Number

Name of next of kin

Contact Ph No

I authorise that the above information may be used to carry out a credit check on me. I also agree that should I be in breach of any express or implied provision of the tenancy agreement or any provision of the residential Tenancies Act, that I will pay the Landlord's costs's incurred in undertaking collection action to recover his/her losses.

Yes No