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FORM #1 - Application

Owner/Agent to Complete

  • Date received: ___________ Time received: __________ __ a.m. __ p.m.
  • ___ # of units available (of the type and in the area) that will be available for rent in the near future by this owner.
  • ___ # of applications previously accepted and remaining under consideration for those units.
  • (If left blank, at least one unit is available and no previously accepted applications currently under consideration have been accepted.)
  • Examined picture identification? ___ Yes ___ No
  • Type of identification? ___________________________________

Rent, Deposit & Fee Disclosure

  • (Amounts listed below are subject to change before the rental agreement is executed)
  • Monthly Rent: $ __________ Security Deposit: $ ___________ Other Deposit: $ _________
  • ___ If checked, Renter’s Insurance is required – Tenant is required to maintain minimum of $100,000 Renter's Insurance and list Owner/Agent as Interested Party. If Tenant(s) combined household income falls at or below 50% of the median for the area, Renter’s Insurance may not be required.
  • Landlord may charge the following:
    • Late payment of rent charge of $ _________
    • Smoke alarm and carbon monoxide alarm tampering fee of $250.00.
    • Dishonored check fee of $35.00 plus amounts charged by bank.
    • Early termination of lease fee not to exceed 1-1/2 times the monthly rent, or actual damages at option of Owner/Agent.
    • Owner/Agent may charge the following non-compliance fees after first giving a written warning notice of initial violation if noncompliance occurs within one year: $50 fee for 2nd violation, and $50 plus 5% of current rent for each subsequent violation. 1. Failure to clean up animal waste, garbage, rubbish or other waste. 2. Parking violation or other improper use of vehicle.
    • Owner/Agent may charge a fee for keeping on the premises an unauthorized pet capable of causing damage, that is not removed within 48 hours of written warning notice. Fee not to exceed $250 per violation.
    • Owner /Agent may charge a fee for smoking/vaping in a clearly designated non-smoking/vaping unit or area of the premises. Fee may be assesed for repeat violations that occur as early as 24 hours after the effective date of a written warning notice, and for each subsequent violation within one year of issuance of written warning notice. Fee not to exceed $250 per violation.

Applicant Screening Charge Disclosure

  1. Owner/Agent may obtain a credit report, or a tenant screening report which generally consists of:
    • a) Credit history including credit report;
    • b) Public records, including but not limited to judgments, liens, evictions and status of collection accounts;
    • c) Current obligations and credit ratings; and/or
    • d) Criminal records or other information verification.
  2. Owner/Agent is requiring payment of an Applicant Screening Charge $ _____ none of which is refundable unless the Owner/Agent does not screen the applicant. This application is valid for up to two weeks from date of receipt by Owner/Agent.
  3. Any charges imposed upon Owner/Agent by a Homeowner's or Condominium Association for anyone who moves into or out of a unit with the association, may be passed through to the Tenant(s) for payment as allowed by law.
  4. If the mail receptacle associated with the dwelling unit is a locking type, Tenant(s) are solely responsible for the fees charged by the Postmaster for the re-keying of the box should a key not be provided by the Owner/Agent, or if the mail box has not been re-keyed between tenancies.

Incomplete applications will not be accepted. Inability to verify information may result in denial of application. I am aware that presentation of false information may result in denial of application or termination of tenancy if discovered within one year of submission of application. I certify the above information is correct and complete and hereby authorize the Owner/Agent to make any inquiries the Owner/Agent feels necessary to evaluate my tenancy and credit standing (including, but not limited to credit reports). If Owner/Agent is requiring payment of an applicant screening charge, I acknowledge receiving a copy of and/or reading Owner/Agent’s Screening Guidelines. I understand that I have the right to dispute the accuracy of any information provided to the Owner/Agent by a screening service or credit reporting agency

No marijuana, medical or otherwise, may be grown, stored or consumed on the premises without the prior written consent of Owner/Agent.


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1462 Commercial St. NE, Salem, OR 97301
Phone: 503-364-5468 | Fax: 503-585-8119

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