Please complete this form and submit for reimbursement. If you have any questions, please feel free to contact the Community Policing division at (563) 587-3807 or Police Administration at (563) 589-4410.

Name*

Business Name

Address*

City, State, Zip*

Phone Number*

Rental Address*

City*

State*

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Zip Code*

Prospective Tenant's First Name*

Prospective Tenant's Last Name*

Date of Birth*

Current Address*

City, State, Zip*

Attended Crime Free Multi-Housing Seminar? *

Yes

No

Date Attended (Month/Year)*

Rental Agreement Outlining Tenant Behavior and Expectations Attached (with Tenant Signature)? *

Attached Previously Submitted

Not available

Upload agreement here

Eviction Policy and Procedure for Tenants or Persons Living in the Rental Property Who Become Involved in Criminal Behavior Attached (with Tenant Signature)?*

Attached Not available

Month to Month Rental

Upload procedure here

Current Rental License*

Yes

No

License Number

Written Screening-Evaluation-Selection Policy Attached? *

Attached Previously Submitted

Not available

Upload policy here

Receipt of Criminal Background Check from Public Agency (attach here) *