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2. Rental Property Location
4. Moorestown, NJ 08057
8. Owner of Record*
9. Last Name*
11. Phone Number
12. Mobile Number
13. Email
15. Street Address*
16. Moorestown, NJ 08057
18. If there is more than 1 owner, list others below.
19. If there is not more than 1 owner, select none.

    1. None
23. Record Owner of Rental Business (if any)
25. If not applicable, select none.

    1. None
27. First Name
28. Last Name
30. Phone Number
31. Mobile Number
32. Email
34. If Record Owner is a corporation, name corporate officers below.
35. Select N/A below if not applicable

    1. N/A

39. If the address of Record Owner is not located in the County in which the premises are located (Burlington County), the name and address of a person who resides in, or has an office in, the County in which the premises are located and is authorized to accept notices from a tenant and to issue receipts therefore and to accept service of process on behalf of the Record Owner:

41. Select N/A below if not applicable

    1. N/A
43. First Name
44. Last Name
46. Phone Number
47. Mobile Number
48. Email
50. Street Address
52. City
53. State
54. Zip
58. Managing Agent
60. Select N/A below if not applicable

    1. N/A
62. First Name
63. Last Name
65. Phone Number
66. Mobile Number
67. Email
69. Street Address
71. City
72. State
73. Zip
77. Individual Employed to Provide Regular Maintenance Service
79. Select N/A below if not applicable

    1. N/A
81. First Name

    Includes superintendent, janitor, or custodian

82. Last Name
84. Phone Number
85. Mobile Number
86. Email
88. Street Address
90. City
91. State
92. Zip
96. Representative of the Record Owner or Managing Agent

    This is an individual representative of the Record Owner or Managing Agent who may be reached or contacted at any time in the event of an emergency affecting the premises or any unit of dwelling space herein, including such emergencies as the failure of any essential service or system and who has the authority to make emergency decisions concerning the building and any repair thereto or expenditure in connection therewith. 

98. Is the same individual as the Owner of Record?*

    1. Yes
    2. No
100. First Name*
101. Last Name*
103. Phone Number*
104. Mobile Number
105. Email*
107. Street Address*
109. City*
110. State*
111. Zip*
113. Name and address of every holder of a recorded mortgage on the premises:
114. Select N/A below if not applicable

     1. N/A
116. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
118. Electronic Signature
120. Are you a "Covered Person" under "Daniels Law?"*
     -- Select One --YesNo
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit

* indicates a required field