Rental Application Form Ut Southwestern (Page 3 of 3) in pdf

X_________________________________________________ Date

Signed:________________________

Applicant’s Signature

__________________________________________________

Please PRINT your full name above

With few exceptions, you are entitled on your request to be informed about the information UT Southwestern collects about you.

Under Sections 552.021

and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the

Texas Government

Code, you are entitled to have UT Southwestern correct information about you that is held by us and that is incorrect, in accordance

with the procedures

set forth in The University of Texas System Business Procedures Memorandum 32. The information that UT Southwestern collects

will be retained and

maintained as required by Texas records retention laws (Section 441.180, et. seq. of the Texas Government Code) and rules. Different

types of

information are kept for different periods of time.

Rev: July 2003

Southwestern Medical Park Apartments

The following notice is provided in accordance with Section 559.003(a) of the Texas

Government Code:

1. With few exceptions, you are entitled on your request to be informed about

the information The University of Texas Southwestern Medical Center at

Dallas collects about you;

2. Under Sections 552.021 and 552.023 of the Texas Government Code, you

entitled to received and review the information; and

3. Under Section 559.004 of the Texas Government Code, you are entitled to

have The University of Texas Southwestern Medical Center at Dallas

correct information about you that is held by The University of Texas

Southwestern Medical Center at Dallas and that is incorrect, in accordance

with the procedures set forth in The University of Texas System Business

Procedures Memorandum 32, Texas Public Information Act.

The information that The University of Texas Southwestern Medical Center at Dallas

collects will be retained and maintained as required by Texas records retention laws

(Section 441.180 et seq. of the Texas Government Code) and rules. Different types of

information are kept for different periods of time.

Please sign that you have read the following information.

_____________________________________________ ____________________

Signature Date

This form must accompany the Rental Application.

Rental Application Form Ut Southwestern Page 3