Blackwell Rentals P.O. Box 2509 - Bloomington, Indiana 47402
Phone: 1-812-333-5300 Fax: 1-812-332-0989 - Email Us

Online Application


Desired Rental Address/Building Name

Personal Information
*First Name:	Middle Initial: * Last Name:
Social Sec. #:
*Date of Birth:
Drivers License #:
*Birth Place
*Current Address:
*Current City/State/Zip:
*How Long at this Address:
*Current Home Phone:	* Cell Phone:
Current Work Phone:
*Current E-mail Address:
Are you a Student?	Yes No
*What year & Major?
Do you have a pet?	Yes No If YES, what kind:
*Names of Roommates:

Current Leasing Information
*Have you ever rented a house or apartment:	Yes No
Present Landlord's Name:
Present Landlord's Phone #:
Previous Address:
Previous Address City/State/Zip:
Previous Landlord's Name

Previous Landlord's Phone:

Legal Questions
Have you ever been evicted from a rental unit?	Yes No If YES, why:
*Have you ever been sued for non-payment of rent?	Yes No If YES, why:
*Do you currently have any outstanding judgments against you?	Yes No

Financial Background
Have you ever failed to timely pay rent?
Have you ever filed for bankruptcy?

Permanent Address Information (Parents)
*Parents' Names:
Permanent Address:
Permanent City/State/Zip
Permanent Phone:
Parent's Work Phone:

Payment Information
Share Your Responsibility for Rent?:

Employment Information
*Current Employer:
Current Occupation:
Full-Time or Part-Time
Current Employer's Address:
Employer's Contact Name:
Current Employer's Phone:
Length of Time with Employer:
Current Salary
*Current Source of Income:

Spouse's Employer:
Spouse's Employer's Address:
Spouse's Employer's Phone #:
Spouse's Wage:

Vehicle Information
Vehicle Make/Model:
Vehicle License Plate #:
State Vehicle is Registered:

Emergency Contact Information
*Emergency Contact's Name:
*Emergency Contact's Relationship:
*Emergency Contact's Phone:
*Emergency Contact's Address:
*Emergency Contact's City/State/Zip:

	By typing "I agree" below, I certify that the answers are correct and that I/We have accurately completed this application. I/We authorize Blackwell Rentals to conduct an employment/credit check and to obtain any other reports necessary concerning me/us as deemed necessary concerning my/our application and to verify all references. I/We understand that such reports may include and are not limited to my credit history, civil and criminal information, arrest records, rental history, employment and financial history, vehicle records, licensing records, and any other information deemed necessary. I/We declare that all information listed on this application is true and accurate. Date I Agree (Type "I AGREE") Applicant's Full Name

*Please enter the above image code:

Blackwell Rentals P.O. Box 2509 - Bloomington, Indiana 47402
Phone: 1-812-333-5300 Fax: 1-812-332-0989 - Email Us

White Iron Data - Bloomington Indiana Website Design
Database Applications, Virtual Tours and Information
Technology Consulting

Online Application

Desired Rental Address/Building Name

Personal Information

Current Leasing Information

Legal Questions

Financial Background

Payment Information

Employment Information

Vehicle Information

Emergency Contact Information