TITUS PROPERTIES
Mail to P.O. Box 467, Gold Beach OR 97444
or FAX to 541-247-2859
Ph: 541-247-4747

Property___________________________________________Rent________( Mo)

Dates of stay_______________________to________________________________

Adult tenants (add second sheet if more than 2):
Name______________________________________________________________
Last First Middle

Date of Birth________________SS#_______________Dr. Lic. #_______________

Address_____________________________________________________________

Phone___________________________Cell_________________________________

Name______________________________________________________________
Last First Middle

Date of Birth________________SS#_______________Dr. Lic. #_______________

Address_____________________________________________________________

Phone___________________________Cell_________________________________

Emergency contact:___________________________________________________
Name
Address_________________________________Phone_______________________

Vehicles to be kept at unit_____________________________ (make, model, state & lic #)
___________________________________________________________________

Names and ages of minor children staying in unit____________________________
___________________________________________________________________

The undersigned (all adult tenants must sign) hereby attests that the above information
is true and authorizes verification of any and all information given:

Name_____________________________________________Date______________

Name_____________________________________________Date______________