<p> Williamsport Lycoming Landlord Association Visit our Web page at LycomingLandlords.org</p><p>Deborah K. Haldeman, President Alan Wilcox, Vice-President Haldeman Housing [email protected] 1656 Memorial Avenue Williamsport, PA 17701 Kermit Grove, Treasurer Phone: 570-321-1122 [email protected] Fax: 570-321-1996 [email protected] Brenda Phillips, Secretary [email protected]</p><p>M e m b e r s h i p A p p l i c a t i o n</p><p>Member Name: ______Contact Name: ______Agency Name: ______Mailing Address: ______Home Ph #: ______Work Ph #: ______Fax #: ______Email: ______</p><p>Number of Rental Properties: ______Type: [ ] Residential [ ] Commercial [ ] Both List complete address location(s) If you need more space please write on backside of this page. </p><p>Property Address # of units Property Address # of units Property Address # of units 1. 9. 17. 2. 10. 18. 3. 11. 19. 4. 12. 20. 5. 13. 21. 6. 14. 22. 7. 15. 23. 8. 16. 24.</p><p>If a member referred you, please tell us who: ______Please tell us if you would be interested in joining a Committee? YES or NO Do we have your authorization; to list your name in the Association brochure? YES or NO Initials: ______to provide your name, phone #, and rental property addresses to Wmspt. Police & Fire Departments in case of emergencies? YES or NO Initials: ______to provide your name, ph #, and rental property addresses to Juvenile Probation & Step, Inc. for the purpose of ulitizing the Community Service Program? YES or NO Initials: ______</p><p>Please remember to sign the Service Authorization Release on the reverse side of this page</p><p>R E S E R V E D F O R O F F I C E U S E O N L Y Check #: ______Ck Date/Membership Date: ______Member ID# ______</p><p>Service Auth. Release Date: ______Member Form Packet Mailed: ______Authorization for Release of Information</p><p>I (we) hereby certify that the information given to me (us) to evaluate rental applicants for tenancy has been completed with applicant(s) signatures and permission for Williamsport- Lycoming Landlord Association to make “any” and all inquires necessary to evaluate applicant(s) for housing. I (we) specifically received authorization from the rental applicant(s) to authorize and request all present or previous employers, mortgage holders, landlords, rental agents, credit grantors, banks, accountants, stock brokers and Local, State or Federal Government Agencies to release any requested information in the evaluation of applicant(s) for rental housing. ______Member Signature Date</p><p>______Member Signature Date</p><p>Please read and sign this form and return to Landlord Association before using Tenant Screening Services.</p><p>Property location(s) [CONTINUED FROM PG. 1] </p><p>Property Address # of units Property Address # of units Property Address # of units 25. 47. 69. 26. 48. 70. 27. 49. 71. 28. 50. 72. 29. 51. 73. 30. 52. 74. 31. 53. 75. 32. 54. 76. 33. 55. 77. 34. 56. 78. 35. 57. 79. 36. 58. 80. 37. 59. 81. 38. 60. 82. 39. 61. 83. 40. 62. 84. 41. 63. 85. 42. 64. 86. 43. 65. 87. 44. 66. 88. 45. 67. 89. 46. 68. 90.</p>