application

Please complete and print the form below. Include $200.00 deposit and mail to

Christine Place Apartments
248 N. MacDonald
Mesa, AZ 85201
Telephone: 480-964-6685
Fax: 480-835-7329

Note: $100.00 of your deposit is a non-refundable cleaning/redecoration fee.

Name:

Telephone:

Street Address:

City, State & Zip:

Length of Time at Current Address:

Previous Address:

Address 2:

City, State & Zip:

Length of Time at Previous Address:

Date of Birth:

Marital Status:

Married

Widow

Widower

Single

Separated

Health Conditions:

Total Monthly Income:

One Bedroom

Apartment Home Desired:

One Bedroom Deluxe

Two Bedroom

If this application is for two people in an apartment, please complete the
following information for the second person.

Name:

Date of Birth:

Relationship:

Health Conditions:

Please supply the following information.

Approx. Time to Start Residency:

Emergency Contact:

Emergency Contact Telephone:

Are you Retired?

Yes

Your Signature:

Today's Date:

Please note that completion and submission of this form does not guarantee definite date of occupancy.

For More Information or Questions contact Christine Place:

Via E-mail:

christineplace@gmail.com

800-751-7796

480-964-6685

Via Phone:

Via Fax:

480-835-7329

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