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110 Schmittle Road
Limitar, NM 87823

Neatly complete all information below. All applicants over the age of 18 must complete and sign their own application.

Today's Date________________________________________

Applicants full name___________________________________Phone #___________________DOB__________

Social Security #____________________Drivers License #____________________State________Exp.________

Current Address________________________________City___________________State________Zip_________

Current Landlords Name__________________________________Landlords Phone # ______________________

How long at this address__________Reason for leaving______________________________________________


Previous Address________________________________City___________________State_______Zip_________

Previous Landlords Name__________________________________________Phone #______________________

How long at this address__________Reason for leaving______________________________________________


Present Employer_____________________________Position__________________Mo. Income______________

Phone #__________________How long at job_________Other income/source____________________________

Employers Address_________________________________________City___________________State________

Number and type of Pets___________________________Have you ever been party to an eviction? [ ] Yes [ ] No

Name of bank_________________________Branch_____________________Type of Account_______________

Name of bank_________________________Branch_____________________Type of Account_______________

Personal References (at least two)

Name______________________________Yrs. Known____Relationship____________Phone #______________

Name______________________________Yrs. Known____Relationship____________Phone #______________

Name______________________________Yrs. Known____Relationship____________Phone #______________

Total number of adults___________Total number of children living with you under the age of 18_____________

Names and relations of all other applicants/occupants__________________________________________________  


Terms of this Rental Agreement (updated 10-14 2006)

Rent:  $450.00 plus utilities:  Gas and Electric

Rent due:  By 10th day of each month. 

Late Fee:  $20.00 due if pay received after the 10th of each month.

Damage Deposit:  $450.00 due with first month's rent (may be applied to final month's rent)

Preferred Length Terms:  1 year lease.   Six month option at $ 500.00 /mo

 Circle Lease Term:   [1 Year]
($450.00/mo) signed _____________     [6 Months ](500.00/mo) Signed____________

Renter Responsibilities:   No Occupants other than those listed on this agreement.  
Additional occupants may be added with modification to this document
More than 2 adults = $50.00 per month per each additional adult. 
No additional mobile homes or camper homes allowed on property.

Renter is responsible for upkeep of yard to include basic weed clearance in timely fashion.
Renter is responsible for lawn maintenance with tools provided by renter or by landlord.
No salvage vehicles allowed on property.
Property Insurance:  Structure and appliances to be covered by landlord's insurance.
Personal Contents' Insurance: Renter is responsible for Renter's Insurance

Additional Comments and Agreements Here:




I CERTIFY that answers given herein are true and complete to the best of my knowledge. I authorize

investigation of all statements contained in this application for tenant screening as may be necessary in arriving at

a tenant decision, I understand that the landlord may terminate any rental agreement entered into for any

misrepresentations made above.


Second Occupant Signature__________________________________________________Date____________________


Carl Jay Gutierrez, MD
3600 Ave du Parc Apt A2809 Montreal, Quebec H2X 3R2 Canada
 Home 514-845-1345 Cell 514 865-3368 Fax 208-460-7831
cjgonline@hotmail.com www.carljay.com  
Copyright 1997-2000 Carl Jay Gutierrez. All rights reserved.