Please enter information directly into this application, print, sign, and attach related documents. Return completed application to:

Thank you for your interest in 4th and Long. For questions regarding the property or this application, please contact Nadine Covalsky, at 815-732-7240, weekdays 8 a.m. to 3 p.m.

4th and Long

Attn: Nadine Covalsky

127 South 4th Street

Oregon, IL 61061	or email to info@4thandlong.us

FOR OFFICE USE ONLY
Address 127 South 4th Street, Oregon, IL 61061	Unit “B” – Retail Storefront
Monthly Rent $510/$485 - $25 discount for auto-pay (includes gas, electric, air conditioning, water, garbage, Internet, security)	Move-in Date

BUSINESS INFORMATION
Business Legal Name	DBA (if different than legal name)
Street Address (not a P.O. Box) City/County State Zip Code
Street Address (if different than above) City/County State Zip Code
**Gross Annual Sales ($)	Federal Tax ID No.	Business Phone No.	Current Landlord Name
Current No. of Employees	Projected Future No. of Employees (Next two years):	Current No. of Company Vehicles	Building is: ☐ Owned. Since ☐ Leased. Since
Date of Formation	Current owner since	Briefly describe the products or services your business sells (e.g., accountant, bakery, etc.)
Organizational Type	Briefly describe any new products or services you are considering offering from this new location.

** Verification of sales, is required. Please provide tax returns, accountant’s statement, or two (2) months of bank statements.

PRINCIPAL/OWNER/GUARANTOR INFORMATION
1	Name	Social Security No.
Home Address City /County State Zip Code
Ownership Percentage:	Gross Monthly Income ($) **
Home is ☐Owned ☐Rented	Personal Net Worth (excluding value of business) ($)
2	Name	Social Security No.
Home Address City /County State Zip Code
Ownership Percentage	Gross Monthly Income ($) **
Home is ☐Owned ☐Rented	Personal Net Worth (excluding value of business) ($)
3	Name	Social Security No.
Home Address City /County State Zip Code
Ownership Percentage	Gross Monthly Income ($) **
Home is ☐Owned ☐Rented	Personal Net Worth (excluding value of business) ($)
4	Name	Social Security No.
Home Address City /County State Zip Code
Ownership Percentage	Gross Monthly Income ($) **
Home is ☐Owned ☐Rented	Personal Net Worth (excluding value of business) ($)

**You need not include alimony, child support, or other income if you do not want it considered as a basis for acceptance.

BUSINESS BANKING INFORMATION
Primary Bank Name	Account No.
Address City /County State Zip Code
Contact Name	Phone No.
Approx. balance in primary bank checking account Approx. balance in other checking account(s) Approx. total balance in savings account(s)

CREDITOR INFORMATION
Creditor Name	Description of Debt	Amount Owed	Monthly Payment
Creditor Name	Description of Debt	Amount Owed	Monthly Payment
Creditor Name	Description of Debt	Amount Owed	Monthly Payment
Creditor Name	Description of Debt	Amount Owed	Monthly Payment

CREDIT CARDS
Type	Card No.
1.
2.
3.
4.
5.

CREDIT REFERENCES List references that you have purchased from on an open account basis (no C.O.D.)
1.	Name	Telephone No.	Account No.
Address City /County State Zip Code
2.	Name	Telephone No.	Account No
Address City /County State Zip Code
3.	Name	Telephone No.	Account No
Address City /County State Zip Code
ADDITIONAL INFORMATION
Has the company or any of its principals, owners, or guarantors ever been evicted or asked to move? ☐Yes ☐No If yes, when?	Has the company or any of its principals, owners, or guarantors made three or more late rental payments in the last year? ☐Yes ☐No If yes, please explain.
Has the company or any of its principals, owners, or guarantors filed for bankruptcy in the last 7 years? ☐Yes ☐No	Has the company or any of its principals, owners, or guarantors had a property foreclosed in the last 7 years? ☐Yes ☐No

The signer(s) hereby certify that he/she is authorized to execute this application on behalf of the above-named business, and that to the best of his/her knowledge, the information provided in this rental application is true, complete, and accurate. The signer(s) hereby authorize a credit and/or criminal check to be made, verification of information provided, and communication with any and all names listed on this application. The signer(s) understand that any discrepancy or lack of information may result in the rejection of this application. The singer(s) understand that a credit report that reveals credit issues such as slow pay, charge offs, collections or judgments could cause the application to be rejected. If the application is denied based on information contained on the credit report, the signer(s) have the right to obtain a copy of such credit report from the reporting agency.

The signer(s) also understand that this is an application for property rental and does not constitute a rental or lease agreement in whole or part. The signer(s) further agree(s) to provide additional information on request and to notify the Landlord promptly of any material change in the information provided in this application.

Signature: ___________________________________ Title: _________________________ Date:________________

Signature: ___________________________________ Title: _________________________ Date:________________

Signature: ___________________________________ Title: _________________________ Date:________________

Signature: ___________________________________ Title: _________________________ Date:________________