| Business name as desired on lease | |
| Property desired | |
| Proposed Use | |
| Rent amount | |
| Email | |
| Phone number |
|
| Present
business address |
(number, street, city, state, and
zip):
|
| Company Tax ID |
|
|
Company Principal #1 or Primary
Contact Person |
Name:
Social Security Number:
Present Residential Address (number, street, city, state,
and zip):
Date of Birth,
format: MM/DD/YYYY:
|
|
Company Principal #1 or Primary
Contact Person |
Name:
Social Security Number:
Present Residential Address (number, street, city, state,
and zip):
Date of Birth,
format: MM/DD/YYYY:
|
| First trade reference and phone | |
| Second trade reference and phone | |
| Former landlord and phone | |
| Bank name and location | |
| Routing number | 
usually located between the symbols on your check.
located at the bottom of the check, it should be 9 digits,
be sure to enter preceding zeros if applicable |
ACH RT number
(if applicable) | ACH RT
some checks have a separate 9-digit ACH RT number printed on the check |
| Account number | 
usually comes before the symbol,
exact location and number of digits varies by bank |
| Rent or deposit amount to be charged |
New applicants enter the amount of one month's rent plus $100 application fee. Initially, only the application fee will be charged. If application is approved, a deposit in the amount of one's month rent will be charged. This deposit is refundable at the termination of the lease provided all terms and conditions of the lease are fulfilled. |
| ePayment Policy | By checking this box, I certify that I have read and agree to the ePayment Policy. |
| Recurring payments | By checking this box, I agree to have my monthly rent debited from my account on the first business day of the each month the lease is in force. Further, I agree to notify Florida Land Group LLC by re-submitting this form or e-mail for any changes to my bank or bank account information. I agree to reimburse FLG for any fees incurred due to my failure to notify. |
| Trade References and Other Notes | |
| Electronic Signature |
By typing my name above, I am electronically signing a draft from an account that I am authorized to withdraw funds from. I understand that fraudulent submission of any account data will be prosecuted to the fullest extent of the law. I am consenting to a credit and background investigation. I have reviewed and agree to the terms and conditions of the lease and the e-payment policy. My bank account will be debited $100 per applicant. If my application is denied, there will be no further debits. If application is approved, a deposit in the amount of one's month rent will be debited. This deposit is refundable at the termination of the lease provided all terms and conditions of the lease are fulfilled. If I decide to not accept the lease and my application is approved, my deposit will be forfeited. My rent will be automatically deducted from this account on the 1st of each calendar month. I agree to notify Florida Land Group LLC with any account number changes. |
