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Advanced Counseling and Therapy Center
The Counseling Center for TRAUMA RELIEF
109 Sahagian Road, Belgrade, Maine 04917 - 207 689-8004

Let's Get Started

Offices:
Belgrade - In person

Connecticut, Maine
Video On Line EMDR

207.689.8004

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Rental Application

Personal Information
Full Application must be completed by every Household Member over the age of 18 years.

Legal First name of Renter

Legal Last name of Renter

Address

Email

Phone

Birthday

Driver's License #

Vehicle Year and Make

2nd Phone

SSN

DL# State of Issue

Vehicle Model

# of Vehicles per Houselhold

# of Houselhold Members

Names/Ages of Additional Household Members

Employment/Income History

Place of Current Employment

Position

Supervisor Name and Position

Start Date

End Date

Monthly Salary

Supervisor Contact Phone #

Previous Employment

Position

Supervisor Name and Position

Start Date

End Date

Monthly Salary

Supervisor Contact Phone #

Other Income Source

Monthly Amount

Additional Income Information

Rental History

Current Landlord

Move-in Date

Move-Out Date

Landlord Address

Landlord Phone Number

Reason for Moving

Previous Landlord

Move-in Date

Move-Out Date

Landlord Address

Landlord Phone Number

Reason for Moving

Questions

Have you ever been evicted? *

No

Yes

Explain

Ever broken a Lease Agreement *

No

Yes

Explain

Are you a Convicted Felon? *

No

Yes

Explain

Are you a Sex Offender? *

No

Yes

Explain

Hav yoe ever been Sued? *

No

Yes

Explain

Have you ever declared Bankruptcy? *

No

Yes

Explain

Do you Smoke? *

No

Yes

Explain

Do you have any Pets? *

No

Yes

Explain

By checking this box I understand I am applying for tenancy, which does not guarantee acceptance. All information provided is accurate to the best of my knowledge. I also grant access for the Landlord to verify any portion of this application, incuding: Background Check and/or Credit Check. I have made no false statements on this application.

Thank you for completing the Rental Application. l will get back to you soon.

Rental Property

109B Sahagian Road

Belgrade, ME 04917

Joel Lavenson

MA, NCC, LPC, LCPC, BCPC, Board Certified PTSD Clinician

109 Sahagian Road, Belgrade, Maine 04917

10 Pond Road, Westport, Connecticut 06880

PH: 207-689-8004

joel@imagotherapist.com

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