Rental Form for DRM Properties APPLICANT INFORMATION Name*Email* Date of birth Date Format: MM slash DD slash YYYY Phone*Social Security Number*Current address:City:State:ZIP Code:Property Ownership:OwnRentMonthly payment or rent:How long?Previous address:City:State:ZIP Code:Property Ownership:OwnRentMonthly payment or rent:How long?Type of Income Check all that Apply SSI SSD VA Benefits Rail Road Benefits Do you have: Medicaid Medicare Next of Kin:Relation to you:Phone:Current AddressCity:State:ZIP Code:For the safety of our residents our company performs background checks.Have you ever been arrested:YesNoCase workerAgencyPhone:Email: Fax:MEDICAL HISTORYPrimary Doctor Name:Address:Number:Primary Diagnosis:Medications:REFERENCESName:Address:Phone:Name:Address:Phone: I authorize the verification of the information provided on this form
