* First Name:   *Last Name:   

Street Address: City:

State: Zip Code:   *Phone Number:      Alternate Phone Number:

Email Address:

*Apartment Size Required: Choose... Studio Two Bedroom Three Bedroom Four Bedroom

Date the Apartment is needed: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2003 2004 2005 2006

Amount of Rent you Pay Now:

*Household Income (Monthly): 

Would you benefit from the features of an accessible unit?  Yes: No:

*Do You Have Pets?  Choose... Yes No

Name of Current Employer/or Source of Income:

 How Long?  1 2 3 4 5 6 7 8 9 10+ Year(s)   0 1 2 3 4 5 6 7 8 9 10 11 Month(s)

*How Many Occupants:  Choose... One Two Three Four Five Six

Why are you looking for a new home?

Name and Relationship of those who will be living in this unit:

 Name: Relationship:

Name: Relationship:

Name: Relationship:

Name: Relationship:

How did you find out about Holsten Management? Sign  Newspaper:  

 Resident/referral  www.holstenchicago.com  Other

*Are you or any other Household Members (Including Minors)

currently a full time student or expect to be in the next 12 months?       Choose... Yes No