Serving Eden, NC & Rockingham County since day one 📞 336-623-8444 | Shane & Abby Hensley

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Eden, NC · Rockingham County

Rental Application

Complete all fields as accurately as possible. Misrepresentation will disqualify your application.

✅ Thank you! Your application has been submitted. Shane or Abby will be in touch with you soon.

⚠️ Something went wrong. Please try again or call us at 336-623-8444.

Applicant Information

Date *

Location / Property

Full Name *

Date of Birth *

Address *

City *

State *

Zip

SS # *

Used for background/credit check only. Submitted securely.

Phone *

How Long at This Address?

Monthly Rent / Mortgage

Landlord Name

Landlord Phone

Previous Address

City

State

Zip

How Long at Previous Address?

Monthly Rent

Landlord Name

Landlord Phone

Work History

Employer *

Employer Phone

How Long?

Employer Address

City

State

Zip

Job Title

Bring Home Pay (Per Month) *

Marital Status *

Married Single Separated

Child Support (per month)

List Names of Spouse and Persons Living With You

Name (Spouse)

Age

SS# (optional)

Name

Age

Name

Age

Name

Age

Personal and Credit References

Reference 1

Name *

Address

Phone *

Reference 2

Name

Address

Phone

Reference 3

Name

Address

Phone

List Loans, Notes, and Other Bills Owed

Creditor / Name

Amount Owed ($)

Monthly Payment

Creditor / Name

Amount Owed ($)

Monthly Payment

Creditor / Name

Amount Owed ($)

Monthly Payment

Creditor / Name

Amount Owed ($)

Monthly Payment

Background Questions

Do you have any pets?

Yes No

What kind of pet(s)?

Have you ever filed bankruptcy?

Yes No

What type of bankruptcy? *

Additional details (optional)

Have you ever been evicted?

Yes No

Have you ever refused to pay rent?

Yes No

Do you have a criminal record?

Yes No

Rental Preferences

Number of Bedrooms Needed *

Price Range (per month)

MISREPRESENTATION ON APPLICATION WILL DISQUALIFY YOU AND VOID LEASE.

I, the applicant, give Shane Hensley permission to check on any information listed above to qualify me for rental property.

Signature

Signature (type your full name) *

Typing your name serves as your electronic signature.

Date *

Leave this blank

Questions? Call us at 336-623-8444

Rent-A-House | Eden, North Carolina | 336-623-8444 | Shane & Abby Hensley