Park Place Associates

Park Place Associates

20 East 12th Street • Bloomsburg, PA • 17815

570.784.8031 • • parkplaceassociates.com

Rental Request Form

Students requesting a tenant lease must complete form indicating desired unit and submit to Kay and Don Camplese at in order to confirm availability.

Apartment/Unit:
Tenant Name:
Home Address:
Cell Phone: / E-Mail:

Bed Request (additional fee of $50 will be added to Fall Semester rent): YES NO Maybe

Parking Request (additional fee of $100 will be charged): YES NO Maybe

Student academic status during lease term: Sophomore Junior Senior Graduate

Financial Aid (copy of award letter may be provided for deferred payment): YES or NO

Additional Information:

Emergency Contact Name:
Relationship:
Address (if different from above):
Cell Phone: / E-Mail: