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First Name (required)

Middle Name

Last Name (required)

Email (required)

Work Phone Number

Mobile Phone Number

Current Address (required)

Date of Birth (dd/mm/yy) (required)

Applying For

What address is this application for?

How Long Have You Lived at Current Address?

Why Are You Leaving?

Number of Bedrooms Required?

Maximum Rent ($)

Number of People Intending to Reside There



Total Number of People Intending to Reside there?

Preferred Areas

Do you Need to Give Three Weeks Notice?

Latest Date Property Required? (dd/mm/yy)

Personal Info


Current Employer

Address of Employer

Phone Number of Employer

Motor Vehicle Make

Motor Vehicle Model

Motor Vehicle Registration Number

Do You Have a Pet?

If Yes, What is the Pet?

Next of Kin?

Relationship of Kin to You

Address of Next of Kin

Phone Number of Next of Kin

Applicants Identification

WINZ Number

Driver's License Number

Landlord References

I AGREE to You Contacting Any of these Referees

Landlord Reference Name 1

Landlord Reference Phone 1

Landlord Reference Name 2

Landlord Reference Phone 2


I consent to Jim Brown Rentals making such enquiries, as they feel necessary to process this application, which may include a credit check. This application is kept for one month only unless we have further contact with you
I Consent to Jim Brown Rentals to Make Enquiries


Code verification, please insert this code in the field bellow

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