RENTAL APPLICATION APPLICANT 2 C: OFFICE USE ONLY Time. Applicant of Agent notified Date. Page 1 of 4

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1 RENTAL APPLICATION This Rental Application is an offer to rent. The Deed of Lease is a legally binding contract. It is unlawful to discriminate on the basis of race, color, religion, national origin, sex, elderliness, familial status or handicap. This application will be processed in accordance with all Fair Housing and occupancy laws. BROKERAGE DISCLOSURE The applicants acknowledge by their initials that in this real estate lease transaction the Listing Broker,, represents the Landlord and that the Leasing broker,, represents the Landlord OR X the Tenant. (If the Broker is acting as a dual representative of both the Landlord and Tenant, then the appropriate disclosure form is attached to and made a part of this Application. Applicants Initials Leasing Agent must attach a business card. Applicants Identification Type & Expiration :. OFFER TO RENT (Applicant 1) and (Applicant 2) offer to lease the property known as, Virginia ("Premises"), for beginning, for the monthly rent of advance on the first day of each month. CONDITIONS yearsmonths payable in A NON-REFUNDABLE PROCESSING FEE OF per Applicant is included with this application. Processing may take up to 5 business days to complete. AN EARNEST MONEY DEPOSIT OF ("Deposit") is included and will be held by. If this Application is accepted, the Deposit will be credited to amounts owed to the Landlord. If this Application is not accepted, the Deposit will be refunded to the Applicant(s) less any additional documented processing charges. Occupancy is subject to possession being delivered by the present occupant. The property is accepted "As Is" unless otherwise noted below or by attachment. CONTACT NUMBERS: APPLICANT 1 C: APPLICANT 2 C: H: W: Application Received Application Reviewed By Approved Rejected Withdrawn H: W: OFFICE USE ONLY Time Applicant of Agent notified Time NVAR - K Rev Page 1 of 4 Keller Williams Alexandria Old Town 607 S Washington Street Alexandria, VA Phone: Fax: Kurt Duty Rental Produced with ZipForm by ziplogix Fifteen Mile Road, Fraser, Michigan

2 APPLICANTS AGREE AND UNDERSTAND THAT: 1. This Application, each occupant and each pet are subject to acceptance and approval by the Landlord. 2. The Listing Company is obligated to present all Applications to the Landlord until the Lease is signed. 3. Landlord and Landlord's Agent may rescind acceptance and resume marketing the Premises at any time until the Lease is signed. 4. Proof of current income is required. For example: Latest Pay StatementsStubs Last 2 years' Form W-2 for hourly or weekly pay persons Last 2 years' Form 1040 and Schedule C (if applicable) of self-employed or persons with tip income Copy of LES and orders for military 5. This Application consists of four pages which must be completed in full. Incomplete or missing information will result in delay of a decision. Willful misrepresentation may be grounds for invalidating a Lease. 6. A draft of the proposed Lease may be reviewed through the Listing Broker. If Landlord and Applicant cannot agree on terms, the deposit will be refunded. 7. Applicant must present valid photo identification or 2 forms of ID before signing the Lease. 8. The Applicant is responsible for obtaining property and liability insurance (Renter's Insurance) and assuming utility accounts where required before occupying the Premises. 9. Any move-in fees and utility deposits are the responsibility of the Applicant. 10. Only those persons listed in the Application are to live in the premises. 11. The Premises are not to be used for business except with full knowledge and consent of the Landlord and in conformity with all applicable laws and regulations. 12. Applicant has no Leasehold interest until the Lease is signed. Iwe agree to the above conditions and authorize the firm processing this Application to verify any information contained herein and to perform any credit or investigative inquiries necessary in properly evaluating this Application, and any renewal. If any information is found to be false or misleading, the Application may be summarily rejected. Signed Applicant 1 Signed Applicant 2 APPLICANT 1 APPLICANT 2 of Birth Social Security Number of Birth Social Security Number Current Street Address Current Street Address City State Zip City State Zip From: To: From: To: s of Occupancy Rent Mortgage s of Occupancy Rent Mortgage LandlordMortgage Company Phone # LandlordMortgage Company Fax # Phone # Fax # NVAR - K Rev Page 2 of 4 Produced with ZipForm by ziplogix Fifteen Mile Road, Fraser, Michigan Rental

3 APPLICANT 1 APPLICANT 2 Previous Street Address Previous Street Address City State Zip City State Zip From: To: From: To: s of Occupancy Rent Mortgage s of Occupancy Rent Mortgage LandlordManagementMortgage Co. LandlordManagementMortgage Co. Phone # Fax # Phone # Fax # EMPLOYMENT EMPLOYMENT Current Company Current Company From: To: From: To: s of Employment s of Employment year PositionRank Income PositionRank Income year Supervisor Phone Supervisor Phone Previous Company Previous Company From: To: From: To: s of Employment s of Employment year PositionRank Income PositionRank Income year Supervisor Phone Supervisor Phone ADDITIONAL INCOME ADDITIONAL INCOME Source year Amount Source Amount year Do you have any animals? LIABILITY COVERAGE IS REQUIRED FOR DOGS. TYPE BREED AGE WEIGHT MF NEUTUREDDECLAWED VEHICLE 1 TYPE, MAKE, MODEL STATE VEHICLE 2 TYPE, MAKE, MODEL STATE NVAR - K Rev Page 3 of 4 Produced with ZipForm by ziplogix Fifteen Mile Road, Fraser, Michigan Rental

4 ADDITIONAL INFORMATION Do you plan to bring a waterbed or large aquarium into the Premises? YES NO Do you intend to smoke or permit smoking in the Premises? YES NO PLEASE ANSWER Applicant 1 Applicant 2 1. Have you ever filed for bankruptcy? Yes No Yes No 2. Have you ever been evicted? Yes No Yes No 3. Do you have any judgments? Yes No Yes No 4. Have you had a foreclosure? Yes No Yes No 5. Are you party to a lawsuit? Yes No Yes No 6. Do you pay alimony or child support? Yes No Yes No 7. Are you a co-signer for a loan or another lease? Yes No Yes No 8. Have you ever had a rental application rejected? Yes No Yes No 9. How would you rate your credit? DEBTS (List major loans or credit card debt) Type of Loan Creditor Balance Monthly Payment ASSETS (Submit supporting documentation if necessary for qualification) Type of Asset 1. Amount 2. OTHER OCCUPANTS OF THE PREMISES (Occupants over 18 must submit separate applications) LAST NAME FIRST NAME AND M.I. MF D.O.B. RELATIONSHIP DESIGNATED CONTACTS (Someone who knows how to reach you) OR NEXT-OF-KIN 1. Relationship 2. Telephone Address City State Relationship Zip Telephone Address City State Zip NVAR - K Rev Page 4 of 4 Produced with ZipForm by ziplogix Fifteen Mile Road, Fraser, Michigan Rental

5 This Agreement is made on EXCLUSIVE RIGHT TO REPRESENT TENANT AGREEMENT ("Tenant") and between ( of brokerage firm) ("Broker"). In consideration of services and facilities, the Broker is hereby granted the right to represent the Tenant in the acquisition of real property. (As used in this Agreement, "acquisition of real property" shall include any lease of property or an agreement to do so.) 1. TENANT'S REPRESENTATIONS. The Tenant represents that as of the commencement date of this Agreement, the Tenant is not a party to a Tenant representation agreement with any other brokerage firm. The Tenant further represents that the Tenant has disclosed to the Associate information about any properties that the Tenant has previously visited at any rental communities or "open houses", or that the Tenant has been shown by any other real estate associate(s) in any area where the Tenant seeks to acquire property under this Agreement. 2. TERM. This Agreement commences when signed and, subject to Paragraph 7, terminates at 9 a.m. X p.m. on,. 3. RETAINER FEE. The Broker,, ( of brokerage firm), acknowledges receipt of a retainer fee in the amount of which shall OR X shall not be subtracted from any compensation due to the Broker under this Agreement. The retainer is non-refundable and is earned when paid. BROKER'S DUTIES. The Broker and the Associate shall promote the interests of the Tenant by: (a) performing the terms of the brokerage agreement; (b) seeking a lease at a price and terms acceptable to the Tenant; (c) presenting in a timely manner all written offers or counteroffers to and from the Tenant; (d) disclosing to the Tenant all material facts related to the property or concerning the transaction of which they have actual knowledge; (e) accounting for in a timely manner all money and property received in which the Tenant has or may have an interest. Unless otherwise provided by law or the Tenant consents in writing to the release of the information, the Broker shall maintain the confidentiality of all personal and financial information and other matters identified as confidential by the Tenant, if that information is received from the Tenant during the brokerage relationship. In satisfying these duties, the Broker shall exercise ordinary care, comply with all applicable laws and regulations, treat all prospective landlords honestly and not knowingly give them false information. In addition, the Broker may: show the same property to other Tenants; represent other Tenants on the same or different properties; represent landlords relative to other properties; or provide assistance to a landlord or prospective landlord by performing ministerial acts that are not inconsistent with the Broker's duties under this Agreement. 5. TENANT'S DUTIES. The Tenant shall: (a) work exclusively with the Broker during the term of this Agreement; (b) pay the Broker, directly or indirectly, the compensation set forth below; (c) comply with the reasonable requests of the Broker to supply any pertinent financial or personal data needed to fulfill the terms of this Agreement; (d) be available during the Broker's regular working hours to view properties. 6. PURPOSE. The Tenant is retaining the Broker for the acquisition of the following type of real property: Rental property to lease. NVAR Page 1 of 3 Initials: Tenant Broker Keller Williams Alexandria Old Town 607 S Washington Street Alexandria, VA Phone: Fax: Kurt Duty Rental Produced with ZipForm by ziplogix Fifteen Mile Road, Fraser, Michigan

6 7. COMPENSATION. In consideration of the time and effort expended by the Broker on behalf of the Tenant, and in further consideration of the advice and counsel provided to the Tenant, the Tenant shall pay compensation ("Broker's Fee") to the Broker as described below. The Broker's Fee, less the retainer fee, if any, shall be earned, due and payable under any of these circumstances whether the transaction is consummated through the services of the Broker or otherwise: (a) If the Tenant enters into a contract to lease real property during the term of this Agreement; OR (b) If, within 356 days after expiration or termination of this Agreement, the Tenant enters into a lease for real property that has been described to or shown to the Tenant by the Broker during the term of this Agreement, unless the Tenant has entered into a subsequent "Exclusive Right to Represent Tenant" agreement with another real estate broker; OR (c) If, having entered into a lease for real property during the term of this Agreement, the Tenant defaults under the terms of that lease. The Broker's Fee shall be 25 percent of one months rent. If the landlord or the landlord's representative offers compensation to the Broker, then the Tenant authorizes the Broker to receive such compensation and the amount of such compensation shall be credited against the Tenant's obligation to pay the Broker's Fee. In addition to the Broker's Fee, an additional fee of 0 will be collected from the Tenant payable to the Broker, at the time the Tenant takes possession of the property. Any obligation incurred under this Agreement on the part of the Tenant to pay the Broker's Fee shall survive the term of this Agreement. 8. The Tenant is participating in any type of employee relocation program Yes OR No. If "Yes": (a) the program is named:, Contract # and (b) terms of the program are:. If "No" or the Tenant has failed to list a specific employee relocation program, then the Broker shall have no obligation to cooperate with or compensate any undisclosed program. 9. DISCLOSED DUAL REPRESENTATION. The Tenant acknowledges that in the normal course of business the Broker may represent landlords of properties in which the Tenant is interested. If the Tenant wishes to acquire any property listed with the Broker, then the Tenant will be represented in one of the two ways that are permitted under Virginia law in this situation. The written consent required from the parties in each case will be accomplished via execution of the appropriate disclosure form at the time of the rental application or lease, whichever is executed first. Dual representation occurs when a Tenant and landlord in one transaction are represented by the same Broker and the same Associate. When the parties agree to dual representation, the ability of the Broker and the Associate to represent either party fully and exclusively is limited. The confidentiality of all clients shall be maintained as in Paragraph 4 above. Designated representation occurs when a Tenant and landlord in one transaction are represented by different Associates affiliated with the same Broker. Each of these Associates, known as a Designated Representative, represents fully the interests of a different client in the same transaction. Designated Representatives are not dual representatives if each represents only the Tenant or only the landlord in a specific real estate transaction. Except for disclosure of confidential information to the Broker, each Designated Representative is bound by the confidentiality requirements in paragraph 4 above. The Broker remains a dual representative. CHECK ONE CHOICE IN EACH SECTION: Dual representation: The Tenant X does OR does not consent to be shown and to consider acquiring properties listed with the Broker through the Associate. Designated representation: The Tenant X does OR does not consent to be shown and to consider acquiring properties listed with the Broker through another Designated Representative associated with the firm. NVAR Page 2 of 3 Initials: Tenant Broker Produced with ZipForm by ziplogix Fifteen Mile Road, Fraser, Michigan Rental

7 10. DISCLAIMER. The Tenant acknowledges that the Broker is being retained solely as a real estate agent and not as an attorney, tax advisor, lender, appraiser, surveyor, structural engineer, mold or air quality expert, home inspector or other professional service provider. The Tenant is advised to seek professional advice concerning the condition of the property or concerning legal and tax matters. The Tenant should exercise whatever due diligence the Tenant deems necessary with respect to information on any sexual offenders registered under Chapter 23 ( et. seq.) of Title Such information may be obtained by contacting your local police department or the Department of State Police Central Criminal Records Exchange, at (804) or EQUAL OPPORTUNITY. Properties shall be shown and made available to the Tenant without regard to race, color, religion, sex, handicap, familial status or national origin as well as all classes protected by the laws of the United States, the Commonwealth of Virginia and applicable local jurisdictions. 12. OTHER PROVISIONS. from lease expiration. This agreement transfers to a buyer broker agreement 90 day 13. MISCELLANEOUS. This Agreement, any exhibits and any addenda signed by the parties constitute the entire agreement between the parties and supersedes any other written or oral agreements between the parties. This Agreement can only be modified in writing when signed by both parties. In any action or proceeding involving a dispute between the Tenant, the landlord andor the. Broker, arising out of this Agreement, or to collect the Broker's Fee, the prevailing party shall be entitled to receive from the other party reasonable attorney's fees to be determined by the court or arbitrator(s). (NOTE: The Tenant should consult with the Associate before visiting any rental properties or contacting any landlords or other REALTORS representing landlords, to avoid the possibility of confusion over the brokerage relationship and misunderstandings about liability for compensation.) Brokerage Firm (Broker) Tenant's Signature (SEAL) Address Tenant's Signature (SEAL) City, State, Zip Code The Tenant does OR does not hold an active or inactive Virginia real estate license. Address BrokerManager's Signature Shane McCullar Kurt Duty City, State, Zip Code Associate'sDesignated Representative's Printed (SEAL) Telephone: Work Home Telephone: (703) Work Home Fax Fax (703) Northern Virginia Association of REALTORS, Inc. This is a suggested form of the Northern Virginia Association of REALTORS, Inc. ("NVAR") This form has been exclusively printed for the use of REALTORS and Non-Resident members of NVAR, who may copy or otherwise reproduce this form in identical form with the addition of their company logo. Any other use of this form by REALTOR and Non-Resident members of NVAR, or any use of this form whatsoever by non-members of NVAR, is prohibited without the prior written consent of NVAR. Notwithstanding the above, no REALTOR or Non-Resident member of NVAR, or any other person, may copy or otherwise reproduce this form for purposes of resale. NVAR Page 3 of 3 Initials: Tenant Broker Produced with ZipForm by ziplogix Fifteen Mile Road, Fraser, Michigan Rental

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