Please Print and fax or email to 928-505-8003
candace@rraz.net

BROOKS-CLARK VACATION RENTAL
APPLICATION
1871 North Kiowa Ave.
Lake Havasu, AZ 86403
Deb 928-486-3637 or Candace 928-706-0070
Fax to 928-505-8003

Last Name __________________________First________________________ Middle____________

Date of Birth_________________ Driver’s License No. ______________________ State: ________
Exp._________

Address: _____________________________________ City: ________________________________

State:_________ Zip:________

Rent Start Date: _______________________ Rent End Date:________________________________

Length of Rent Period: __________ Total No of Occupants: _________

Ages of Occupants:____________________________

Charges Authorized:
Rent: $_______
Security Deposit: $ ______ Refundable inspection and damage report
Cleaning Fee: $ 120.00 Non-refundable
3% Credit Card Fee $_______
10.85% Sales/City Tax $_______ Only charged if less then 30 days.

Total Amount Due: $_______

3% charge for use on Rental Fees (not on Deposit)
Credit Card Type: ___________________________
Credit Number:______________________________

CC Exp. Date: _____________________ CSC/CVV/CVS No.: __________ (AMEX 4 digits front/Visa
& MC 3 digits back)

Name on CC: ___________________________________ CC Bill Address: ______________________
Employer ___________________________ Position ___________________ Phone No.: ____________
Address: ___________________________________ City: _______________________ State: ________
Zip: __________
References/Emergency Contacts
Name: ____________________________Yrs Known: ________ Relationship: _______________ Phone #: ______________
Name: ____________________________Yrs Known: ________ Relationship: _______________ Phone #: ______________

I CERTIFY that all of the information stated here is true and correct to the best of my knowledge. I authorize investigation of all statements contained in this application for tenant screening as may be appropriate to arrive at a tenant decision. I agree that the landlord may terminate the rental agreement for any misrepresentations made above. I agree to supplement the information listed
above, regarding rental period and occupants if changes do occur. I understand that credit cards are accepted with a three percent (3%) transaction fee. I have read, understand and agree to all of the terms of the rental agreement.

Renter Signature: __________________________________________Date:


- Vacation Rental Application