Have you ever been convicted of a crime (other than traffic infractions)? Yes □ No □ (If yes, give details: ) Acknowledgment and authorization: By signing this agreement: I declare that all of my responses are true and complete. Any false statements or inaccurate information made on this application can, lead to the rejection of my application and/or the immediate termination of my lease and further legal action. I authorize Landlord/Owner or agent, to verify this information (including employment, income, landlord, criminal and sex offender search). I authorize the Landlord/Owner or agent, to obtain my Credit Report during the application period, lease period and throughout any period of indebtedness. I further authorize credit reporting agencies, past or present employers and landlords to verify or provide Landlord/Owner or agent, with any and all information requested, and such information may be verified or provided at the time of submission of my rental application, during the entire lease term and in the event that I enter into a Lease Agreement with Landlord/Owner, and thereafter as long as I owe any balance to Landlord/Owner. Landlord/Owner or agent, may obtain information from any source and may exchange credit information with consumer reporting agencies. I agree to hold Landlord/Owner and any affiliates, harmless for any claims that may arise as a result of this investigation. I understand that this notice will also apply to future update reports that may be requested. All copies of statements and/or documents submitted or obtained in connection with this rental application will have full force and effect as though it were the original document. I have read and understand all information and statements. I understand and acknowledge that Landlord/Owner has given me a full and fair opportunity to seek advice from legal counsel prior to signing this rental application. Printed Name Date Signature **RATES, SPECIALS AND FEES ARE SUBJECT TO CHANGE AT ANY TIME.
Have you ever had a concussion, or hit to the head causing confusion, headache and memory problems? 11. Do you have any problems with your eyes or vision?
Have you ever been convicted or found guilty by a Court of any offence in any country (excluding parking but including all motoring offences even where a spot fine has been administered by the police) or have you ever been put on probation or absolutely/conditionally discharged or bound over after being charged with any offence or is there any action pending against you? You need not declare convictions which are “spent” under the Rehabilitation of Offenders Act (1974). Yes/No* (If yes please give details here)
Have you ever had a license (other than a driver's license) revoked or suspended? Yes No
Have you ever been the subject of a civil lawsuit involving, or an investigation or allegation of, sexual misconduct, sexual harassment, or other immoral behavior or conduct, involving adults or children? If yes, please describe the circumstances and provide the name and address of the employer, educational institution, church, or other organization where the lawsuit, investigation, or allegation arose or occurred.
Have you ever in your WHOLE LIFE, tried to kill yourself or made a suicide attempt? Yes No Complete if 11 yrs. or older GAD-7 Over the last 2 weeks, how often have you been bothered by the following problems? (Use “✔” to indicate your answer) Not at all Several Days Over Half of the Days Nearly Every Day
Have you ever been terminated from a job for a conduct or performance related cause? If yes, please provide the circumstances. (A layoff, work force reduction, relocation, or non-performance/conduct related termination doesn’t need to be described.) I understand termination for cause may not always be a candidate’s fault. I need to know the circumstances so I can be prepared to address this with a potential client if brought up. I always try to fairly understand these types of situations.
Have you ever. X. Had a complaint filed against You with an Insurance Department. YES NO (If “Yes”, what state? )
Have you ever withdrawn from a postgraduate training program or been suspended or removed from practice during a postgraduate training program?
Have you ever a. Had insurance refused, or offered only with an extra premium? . . . . . . . [ ] Yes [checkmark] No b. Been arrested and convicted for a felony offense? . . . . . . . . . . . . . [ ] Yes [checkmark] No 7. HAVE YOU IN THE LAST 5 YEARS: (IF YES, EXPLAIN) a. Used hallucinogenic or narcotic drugs not prescribed by a doctor? . . . . . [ ] Yes [checkmark] No b. Used alcoholic beverages? (Note type, quantity and frequency) . . . . . . . [ ] Yes [checkmark] No c. Had or been advised to have medical treatment or counseling from a commonly recognized practitioner or organization for alcohol or drug use?. [ ] Yes [checkmark] No 8. a. Have you smoked cigarettes within the past 12 months? . . . . . . . . . . . [ ] Yes [checkmark] No Information If Yes, how much? . . . . . . . . . . . . . . . . . . . . . . . . . . . . --------------------- b. If No, have you used any other tobacco products within the past 12 months (e.g. cigar, pipe, smokeless tobacco)? . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No If Yes, have you smoked cigarettes within the past 10 years? . . . . . [ ] Yes [checkmark] No c. Have you used any nicotine substitutes within the past 12 months (e.g. patch, gum)? . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Yes [checkmark] No --------------------- Height & 9. a. What is your current height? . . . . . . . . . . . . . . . . . . . . . . . . 6
