Contact Information

Full Name:
Phone Number:
Email Address:
Address:
City:
State:
Zip Code:

Rental Details

Preferred Check-in Date:
Preferred Check-out Date:
Bungalow Size (Select One):
1-Bedroom2-Bedroom4-Bedroom

Rental Duration:
DailyWeekendWeeklyMonthly

Occupancy Information

Number of Adults:
Number of Children:
Total Number of Guests:
Do you have any pets?
YesNo

If yes, please specify the type and number of pets:

Residence Information

Current Residence Address:
Residence City:
Residence State:
Residence Zip Code:
Is this your primary residence?
YesNo

Do you own your primary residence or rent?
OwnRent

If renting, please provide your landlord's name and contact information for reference:
Landlord’s Name:
Landlord’s Phone Number:

Additional Requests

Do you require any special accommodations? (Please specify):

Payment Information

Preferred Payment Method:
Check made out to Renovate RXOther

Agreement

I agree to abide by the property rules and regulations

Signature:
Date:

Instructions for Applicants:

1. Fill out the form completely: Make sure all fields are filled out accurately.

2. Submit the form: Send the completed form to Heimishretreat@gmail.com or bring it with you to the open house.

3. Contact us: If you have any questions or need assistance, please call us at 845-903-3126.