This is the actual form....sorry.
<html>
<head>
<title>Application</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<link rel="stylesheet" href="mm_derosa.css" type="text/css" />
</head>
<body bgcolor="#0066cc">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr bgcolor="#99ccff">
<td width="15" nowrap="nowrap"> </td>
<td width="745" height="60" colspan="3" class="logo" nowrap="nowrap"><br />
Application <span class="tagline">| DeRosa Rentals </span></td>
<td width="100%"> </td>
</tr>
<tr bgcolor="#003399">
<td width="15" nowrap="nowrap"> </td>
<td height="36" colspan="3" id="navigation" nowrap="nowrap" class="navText"><a href="javascript:;">HOME</a></td>
<td> </td>
</tr>
<tr bgcolor="#ffffff">
<td width="15" valign="top"><img src="mm_spacer.gif" alt="" width="15" height="1" border="0" /></td>
<td width="140" valign="top"><img src="mm_spacer.gif" alt="" width="140" height="1" border="0" /></td>
<td width="505" valign="top"><br />
<table border="0" cellspacing="0" cellpadding="2" width="600">
<tr>
<td width="536" class="pageName">Application</td>
</tr>
<tr>
<td class="bodyText">
<p><form name="form" action="http://www.derosarentals.com/verification.php" method="post">
<table width="100%" border="0" cellpadding="0" align="right">
<tr>
<td width="60%"><b>Applicant 1</b></td>
<td width="40%"><b>Applicant 2</b></td>
</tr>
<tr>
<td width="60%" height="30"><font size="-1">Name:</font>
<input name="first1" size="10" > <input name="last1" size="20" ></td>
<td width="40%" height="30">
<input name="first2" size="10" > <input name="last2" size="20" ></td>
</tr>
<tr>
<td width="60%" height="28"><font size="-1">Address:</font>
<input name="address1" size="20" ></td>
<td width="40%">
<input name="address2" size="20" ></td>
</tr>
<tr>
<td width="60%" height="27"><font size="-1">City, State:</font>
<input name="city1" size="15"> <input name="state1" size="3"></td>
<td width="40%">
<input name="city2" size="15"> <input name="state2" size="3"></td>
</tr>
<tr>
<td width="60%"><font size="-1">Zip:</font>
<input name="zip1" size="7"></td>
<td width="40%">
<input name="zip2" size="7"></td>
</tr>
<tr>
<td width="60%" height="29"><font size="-1">DOB:</font>
<input name="dob1" size="15"></td>
<td width="40%">
<input name="dob2" size="15"></td>
</tr>
<tr>
<td width="60%"><font size="-1">SSN #:</font>
<input name="ssn1" size="13"></td>
<td width="40%">
<input name="ssn2" size="13"></td>
</tr>
<tr>
<td width="60%" height="29"><font size="-1">Driver License:</font>
<input name="driver1" size="20"></td>
<td width="40%">
<input name="driver2" size="20"></td>
</tr>
<tr>
<td width="60%" height="28"><font size="-1">Phone (day):</font>
<input name="dayPhone1" size="15"></td>
<td width="40%">
<input name="dayPhone2" size="15"></td>
</tr>
<tr>
<td width="60%" height="27"><font size="-1">Home Phone:</font>
<input name="homePhone1" size="15"></td>
<td width="40%">
<input name="homePhone2" size="15"></td>
</tr>
<tr>
<td width="60%" height="30"><font size="-1">Occupation:</font>
<input name="occupation1" size="20"></td>
<td width="40%">
<input name="occupation2" size="20"></td>
</tr>
<tr>
<td width="60%" height="28"><font size="-1">Employer:</font>
<input name="employer1" size="20"></td>
<td width="40%">
<input name="employer2" size="20"></td>
</tr>
<tr>
<td width="60%" height="27"><font size="-1">Employer's Address:</font>
<input name="empAddress1" size="20"></td>
<td width="40%">
<input name="empAddress2" size="20"></td>
</tr>
<tr>
<td width="60%" height="27"><font size="-1">City, State, Zip:</font>
<input name="city_1" size="15">
<input name="state_1" size="3"> <input name="zip_1" size="4"></td>
<td width="40%">
<input name="city_2" size="15">
<input name="state_2" size="3"> <input name="zip_2" size="4"></td>
</tr>
<tr>
<td width="60%"><font size="-1">Salary: $</font>
<input name="salary1" size="10"></td>
<td width="40%">
$
<input name="salary2" size="10"></td>
</tr>
<tr>
<td width="60%" height="28"><font size="-1">Length of Employment:</font>
<input name="length1" size="3"></td>
<td width="40%">
<input name="length2" size="3"></td>
</tr>
<tr>
<td width="60%" height="28"><font size="-1">Bank:</font>
<input name="bank1" size="20"></td>
<td width="40%">
<input name="bank2" size="20"></td>
</tr>
<tr>
<td width="60%" height="28"><font size="-1">Bank's Address:</font>
<input name="bankAddress1" size="20"></td>
<td width="40%">
<input name="bankAddress2" size="20"></td>
</tr>
<tr>
<td width="60%" height="28"><font size="-1">Checking Account #:</font>
<input name="checking1" size="20"></td>
<td width="40%">
<input name="checking2" size="20"></td>
</tr>
<tr>
<td width="60%" height="27"><font size="-1">Current rent/mortgage: $</font>
<input name="rent1" size="10"></td>
<td width="40%">
$
<input name="rent2" size="10"></td>
</tr>
<tr>
<td width="60%" height="27"><font size="-1">Current Landlord:</font>
<input name="landlord1" size="20"></td>
<td width="40%">
<input name="landlord2" size="20"></td>
</tr>
<tr>
<td width="60%" height="26"><font size="-1">Current Landlord's Phone:</font>
<input name="landlordPhone1" size="15"></td>
<td width="40%">
<input name="landlordPhone2" size="15"></td>
</tr>
<tr>
<td width="60%"><font size="-1">Additional Occupant(s):</font>
<input name="occupats1" size="20"></td>
<td width="40%"><input name="occupats2" size="20"></td>
</tr>
<tr>
<td><font size="-1">
<b>Please check information for any mistakes.</b></font></td>
<td><font size="-1">
<input type=submit value="Submit"> <input type=reset value="Clear"></font></td>
</tr>
</table>
</form></p>
<br/></td>
</tr>
</table>
<br />
<br /> </td>
<td valign="top"> </td>
<td width="100%"> </td>
</tr>
<tr>
<td width="15"> </td>
<td width="140"> </td>
<td width="505"> </td>
<td width="100"> </td>
<td width="100%"> </td>
</tr>
</table>
</body>
</html>