Maintenance Request Form

First Name (required)
Last Name (required)


Building (required)

Unit# (required)

Your Email (required)

Cell Phone Number


COVID – 19: TENANT SCREENING FORM LIABILITY RELEASE WAIVER

ALL QUESTIONS MUST BE ANSWERED

TRAVELED IN THE PAST 14 DAYS Yes No 
BEEN IN CONTACT WITH A COVID POSITIVE PERSON Yes No 
FEVER Yes No 
COUGH Yes No 
SORE THROAT Yes No 
NAUSEA/VOMITING Yes No 
DIARRHEA Yes No 
HEAD ACHE Yes No 
DIFFICULTY BREATHING / SHORTNESS OF BREATH Yes No 
MUSCLE / JOINT PAIN Yes No 
LOSS SMELL / TASTE Yes No 

 I acknowledge that I fully understand all the above questions and have answered them fully and truthfully. This acknowledgment of truthfulness of the absence of any COVID symptoms shall be the basis upon which the Landlord and its employees/agents/contractors, etc. are entering my apartment. I hereby release waiver, discharge the Landlord, its agent, their boards, officers, independent contractors, affiliates, employees, representatives, successors and assigns from any and all liabilities, claims, demands, actions and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury or death, that may be sustained by me related to COVID-19 while in, on or around the Leased Premises and the Building and its common areas that may lead to exposure or harm due to COVID-19.


Description of Work
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I, undersigned, hereby acknowledge that I requested the above repairs and maintenance to be done to my suite. I desire that the said repairs and maintenance be attended to as soon as possible from the date of this request, and for such purpose, I give you permission to enter my suite during reasonable daylight hours in order to effect such repairs, without the need for you to provide me any advance written notice of such date and time of entry. This acknowledgement shall operate as my consent at the time of entry for you to enter my suite in order to affect such repairs notwithstanding my absence from the suite at the time of such entry and at the time that such repairs are made. It is hereby acknowledged that broken windows, fuses and electrical bulbs are to be replaced by me at my expense.

 I AGREE with all the above terms and conditions.

 I AGREE THAT MY TEXT-TYPED SIGNATURE SHALL CONSTITUTE MY ELECTRONIC SIGNATURE.

Signature: