08/08/2023
Application
Black Dog Properties
552 South Trimble Road
Mansfield, Ohio
419-756-0188
Applicant Consent Form for Tenant Screening Investigation & Specific Release
Background Rental Check
1.) First Name:______________________________ Last Name:___________________
2.) SS # : _________-_____-_______
3.) Date of Birth: _____-_____-_______
4.) Address: Street:_______________________________________________________ City__________________________State___________ Zip Code___________ How Long at this address?_________________________________________
5.) E-Mail: ______________________________________________________________
6.) Phone:_______________________________________________________________
7.) Cell Phone:___________________________________________________________
8.) Place of Employment:__________________________________________________ Position:_________________________________How Long?_____________
9.) Previous Employment:__________________________________________________ Position:__________________________________How Long?____________
10.) Drivers License Number & State:____________________________________
11.) References: Name:_______________________________________________ Phone Number:________________________________________ Name: _______________________________________________ Phone Number:________________________________________
12.) Banking:
Checking: Bank:__________________________________________
Address:____________________________________________________
____________________________________________________________
Account
Savings: Bank:____________________________________________________
Address:___________________________________________________
___________________________________________________________
Account #: ________________________________________________________
I certify and declare under penalty of perjury under relevant state and federal law that the information contained in my employment/leasing application is complete, true, and accurate. I acknowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of employment/lease.
In consideration of Black Dog Properties, L.L.C. (herein referred to as LANDLORD) review of my application for employment/leasing, I hereby voluntarily consent to and authorize LANDLORD, or its authorized agents bearing this release or copy thereof, to obtain a consumer report for employment/leasing purposes. I agree that this consumer report may include any of the following:
• Employment Verification, Education Verification, Credentials Verification
• Personal Identity Verifications, Past Employment Verification, Reference Checks
• Criminal Records, Civil Cases, Motor Vehicle Records, Credit Report
I authorize all persons and organizations that may have information relevant to this research to disclose such information to LANDLORD or its authorized agents. I hereby release LANDLORD, its authorized agents, and all persons and organizations providing information from all claims and liabilities of any nature in connection with this research. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original.
I understand that I have specific prescribed rights as a consumer under the federal Fair Credit Reporting Act ('FCRA') and may have additional rights under relevant state law. I hereby certify that I have been presented with a summary of my rights as a consumer under the Fair Credit Reporting Act.
_____________________________________________ _________
Signature of Applicant Date
______________________________________________
Printed Name
