1056 Gillespie Street, Schenectady, NY  12308

Please submit a separate application form for each adult who will live in the apartment.

Name ____________________________________

Phone ___________________

Mailing Address _______________________________

City/State _________Zip_________

Email ________________________________

Are you over 21? _______

Are you a US citizen? ______
If no, what is your immigration status? ___________________


Employer’s Phone Number __________________________
How long employed there? ____________________________
Take-home pay: $__________
( ) weekly  ( ) bi-weekly  or ( ) monthly ?

If less than two years, list previous employer _________________________________________
Previous Employer’s Phone Number ______________________________


Where are you living now? Address: ____________________________________________
Current landlord, building supervisor, or mortgage holder: ___________________ Phone# _____________________
If less than 3 years, please give previous address: _______________________________________________

Name of previous landlord, building supervisor, or mortgage holder: ___________________Phone# _____________


Vehicles/boats to be parked on premises or street
(make/model/year/license #):
Make / Model ____________________________ Color ______Year _______
Make / Model ____________________________ Color ______Year _______

Pets (describe) _______________________________________________

Do you smoke? _______________________________________________

Have you ever been delinquent in paying rent or other financial obligations? If yes, please explain:

Have you ever failed to perform any obligations of a rental agreement, or have you ever been a defendant in an eviction lawsuit? If yes, please explain:


Who will live with you the apartment? (list all occupants, including roommates, children & infants)  _______________________________________________

Will there be any extended guests? (IE: frequent visitor, extended house guest, additional roommate, additional family member)


Will any of the residents or visitors bring a pet? (Describe) __________________________________________

Do any of the residents or frequent visitors smoke? _______________________________________

REFERENCES (Landlord, Building Supervisor, Employer, or other persons who know you well)

Name                Relationship         Phone or email address



I hereby certify that the above information is true and correct to the best of my knowledge. I hereby authorize Jackie Craven or her agent to contact my references, to verify the information I have given, and to obtain consumer or investigative credit reports, criminal background reports, and/or eviction records. I understand that I may be asked for a social security number and photo identification before signing a lease.

Signature: ___________________________________________

Date: ____________________________

By submitting this application, you express interest in renting the apartment named above. This application is not a lease or a binding agreement. Other prospective renters may also submit applications until a lease has been signed.