205-f south duffy rd.

butler, pa 16001

This section for office use only:

Today’s Date:___________________

Unit Desired Estimated Move-In Date Security Deposit Rental Rate

$ $
Place “X” in boxes of Utilities Paid by Resident Additional Provisions

Electric Water Internet

Cable Sewer
Phone Garbage

The Highlands Apartments requires a copy of current PA driver’s license or other form of state-issued photo ID, a
copy of your social security card as well as your most recent year’s W-2 or 1099 and current pay stub in addition
to this form.
Each adult (18+) resident is required to fill out a separate application. A non-refundable fee of $25.00 for each
applicant is due with completion of this form

APPLICANT’S PERSONAL DATA: Home Phone:_______________ Cell: ________________Work:__________________

Email:_________________________________________________________________

Full Name Social Security # Driver’s License # State Birth Date

All other names by which you have been known:

MINORS TO OCCUPY THE PREMISES:

Full Name Relationship Age

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APPLICANT’S EMPLOYMENT OR INCOME HISTORY (List ALL employers for the past 2 years. Start with present.)

Company Name Address Gross Monthly

Phone # Position Dates
or Source of Income Please include city & zip Income

RESIDENCE HISTORY: (List ALL residences for the past 2 years. Start with present.)
Street Address Landlord Name
City State Zip Dates Rent
and Apartment # and Phone #

PERSONAL REFERENCES: ( Cannot be related or living in same household.)

Full Name Relationship Address Phone Number

IN CASE OF EMERGENCY NOTIFY:

Full Name Relationship Address Phone Number

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VEHICLES:

Make Model Color Year License Plate # Insurance Company

PLEASE ANSWER THE FOLLOWING QUESTIONS: Y N

Has any civil judgement been entered against you for the collection of any debt in the past 10 years?
Have you filed for bankruptcy in the past 10 years?
Have you been evicted or refused to pay rent for any reason?
Have you ever possessed, sold, or used illicit drugs or narcotics in or about your residence?
Have you ever been convicted of or pled guilty or “no contest” to a felony, misdemeanor or sexual offense?
Have you ever been delinquent in rent over 30 days?
Does your current landlord know you are moving?
Do you have a pet?
If you answered “yes” to any of the above, please explain completely. (use back of this sheet if necessary):

How did you FIRST hear about our community?

Butler Eagle YellowBook Friend Other:
CenturyLink Yellow Pages Internet Search Company
How long do you expect to stay?_______________________________________________________________________

That all information herein set forth is TRUE and CORRECT and may be incorporated by reference
into the Lease Agreement, if issued;
That any false statement or misrepresentation in this application shall be grounds for refusal to
rent an apartment to the undersigned and, if a lease is issued, shall also constitute an act of default
and grounds for forfeiture of the Lease Agreement, in the sole discretion of the Lessor;
That Lessor is hereby authorized to check credit references and any other information shown on
this application, now and for as long a time as any charges are still due under our lease;
That the undersigned is applying for an apartment for personal occupancy as herein set forth and
not on behalf of any other individual or individuals;
That the undersigned agrees that the maximum occupancy for a 1-bedroom apartment is two (2)
persons and for a 2-bedroom apartment occupancy is four (4) persons and that no individuals will
be permitted to occupy the same other than those named in this application; and
That the undersigned agrees to be bound by all of the Rules and Regulations of Lessor referred to
in the Lease Agreement.
BY SIGNING THIS APPLICATION, YOU DECLARE THAT ALL OF YOUR RESPONSES ARE TRUE AND COMPLETE AND
AUTHORIZE AGENT OF LESSOR TO VERIFY THIS INFORMATION, REFERENCES, AND CREDIT RECORDS AND PERFORM
A CRIMINAL BACKGROUND CHECK. ANY FALSE STATEMENT ON THIS APPLICATION CAN LEAD TO REJECTION OF
YOUR APPLICATION OR IMMEDIATE TERMINATION OF YOUR LEASE.

Date Applicant’s Signature Applicant’s Name PRINTED

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 Information for Prospective Residents
Thank you for inquiring about The Highlands Apartments, Inc. Please read and review this page carefully as it
highlights a few procedures and estimated costs regarding your residence with The Highlands Apartments.
Procedures:
No two residents are exactly the same. Here are a few simple ways we can unify everyone’s enjoyment of the
premises (A more comprehensive list of tenant obligations will appear on the lease if you should decide to
join our community).
1. Keep your apartment, balcony, patio, etc. & surrounding areas clean.
-Do not leave unattended items in yards or hallways, especially near where people walk.
-If you smoke, do not throw cigarette butts on the porches, sidewalks, shrubs, lawn, etc.
-Throw all garbage in provided receptacles.
-Clean and change filter on air conditioning unit.
2. Respect the rights and property of others.
-Respect privacy
-Do not touch or allow your family or guests to touch other’s property. This includes cars, entry doors,
screen doors, etc.
3. Quiet Enjoyment.
-Keep the volume of your television/stereo, as well as voice at a reasonable level, especially during
early morning (before 9:00am) & late night (after 10:00pm).
4. Parking.
-We have plenty of parking available at each building. We ask, however, that if you own multiple cars,
please park one at the back of your parking lot so that everyone may have one close parking space.
5. Test your smoke detector.
6. Provide white drape liners or white backed drapes so that all buildings have a uniform look.

Costs to help you plan your budget:

(This is not an all-inclusive list & is meant only to help you estimate. Only you will know all of your expenses and can make a
well-informed decision. )
The Highlands Apartments requires each tenant to carry renter’s insurance with $300,000.00 liability coverage.
This is will cover you should you be found responsible for damages by fire, etc. Check with your insurance
agent for prices.

A security deposit is due at move-in. Upon move-out, cost for professional steam cleaning of carpet will be
deducted from this amount.

You are responsible for your electric bill. Because heat & a/c are part of the electric bill, it is difficult to
determine the cost. You are encouraged to contact Allegheny Power for information and past average costs for
your future address.

Cable, telephone and internet will all be your responsibility (should you decide to utilize these services).
Contact the local provider for pricing information. Be advised that any television system that requires the use
of a satellite dish or any drilling through exterior walls will not be permitted.