Fillable City Of Dubuque Prospective Tenant Background Check Consent Form printable pdf download

City Of Dubuque Prospective Tenant Background Check Consent Form

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City of Dubuque

Prospective Tenant Background Check Consent Form

Last Name

First Name

Middle Name

Any Other Names Used

Phone Number(s)

Date of Birth

Sex

Social Security Number

Current Address:

Three (3) Prior Addresses (Include City, State, Zip)

► Additional household members eighteen (18) years or older: (Name, Date of Birth)

(Additional household members eighteen (18) years or older must also complete a Prospective Tenant Background Check Consent Form)

Number of household members under eighteen (18) years of age:

Have you been convicted of a felony or a serious or aggravated misdemeanor in the past five (5) years?

I hereby consent to the use of the above information to search my criminal history records. I am of legal age and sign this as

my own free act and deed. I understand what this document means and what I am agreeing to by signing it.

Signature

Date

DISCLAIMER: This information is being provided at the request of Landlord, and in accordance with the written instructions of the individual to whom it

relates, and Landlord agrees that the decision to rent is Landlord's SOLE decision. The city of Dubuque is not an agent of Landlord nor does it guarantee or

warrant the character or suitability of a tenant. The city is simply providing information requested.

RESULTS

To be Completed by Landlord

Property Agent

Name of Property

Property Address (Include Apt. #)

Number of Bedrooms in Unit

Fax #

Phone #

Date

For Internal Use by City Only

Form Received by: