§106. REGISTRATION FORM.
Borough of Mount Pocono Tenant Registration Form
1361 Pocono Boulevard, Suite 100
Mount Pocono, PA 18344
Tel. # (570) 839-8436/Fax# (570) 839-0981
Lessor/Lessee Statement
Please refer To the Attached Instruction Information
1. We (I) are leasing the following residential property (unit) within Borough of Mount Pocono
Property ID (Pin #):__________________________
Address of property:__________________________ Lessor: ________________________________________
____________________________________________ Address: ______________________________________
Telephone: __________________________________ ______________________________________________
Emergency Telephone: _______________________ Telephone: ____________________________________
2. Lessee information: (please print)
Lessee #1 Lessee #2
Name: __________________________________ _____________________________________
Employer Name: __________________________________ ______________________________________
Employer Address: __________________________________ ______________________________________
Employer Telephone: __________________________________ ______________________________________
*Term of agreement Start Date ________________________ End Date ____________________________
3. Names of children or other individuals who will reside with the lessee: (please print)
Name Date of Birth Relationship to Lessee
___________________________________ _____________________ _____________________________
___________________________________ _____________________ _____________________________
___________________________________ _____________________ _____________________________
Please use the back of this form for additional names
4. Total square footage of rental area: ______________ sq. ft. Number of bedrooms: _____________
5. Number of Required Smoke Alarms: ______ Battery: (y/n) _____ Electrically Wired: (y/n) _____
6. I (We) understand that I am to notify Lessor and Borough Zoning Office of any changes to the occupancy of this premises within
five days of change.
7. I (We) verify that the facts set forth in this application are to the best of my (our) knowledge, information and belief. This
verification is made subject to the penalties of Section 4904 of the Crimes Codes (18 Pa.C.S. §4904) relating to Unworn falsification to
authorities.
______________________________________________ __________________________________________
(lessee) (lessee)
Date __________________
______________________________________________ __________________________________________
(lessor) (authorized agent)
Date __________________
Please check one:
_____ Annual
_____ Change of Occupancy
This form must be returned!
*When a tenant moves out and a new tenant moves in a Borough Inspection is required.
