Residential Rental Application
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4STATE OF CALIFORNIA - DEPARTMENT OF TRANSPORTATION
RESIDENTIAL RENTAL APPLICATION
Page 1 of 4
RW 11-5 (Rev. 6/99)
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Section 1798, et seq.), notice is hereby given for the request of personal information by this form.
The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested
information may delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right,
upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your
IPA Officer.
THE LAW PROHIBITS DISCRIMINATION IN HOUSING — — — — DISCRIMINATION BASED ON RACE, COLOR, RELIGION, SEX, MARITAL
STATUS, NATIONAL ORIGIN OR ANCESTRY IN THE SALE, RENTAL, OR LEASING OF HOUSING, ACCOMMODATIONS IS PROHIBITED
BY THE CALIFORNIA FAIR HOUSING ACT, HEALTH AND SAFETY CODE, SECTION 35700 AND TITLE VI OF THE 1964 CIVIL RIGHTS
ACT (42 U.S.C. 2000d, et seq.). If you believe that you have experienced discrimination in the rental of State housing, please contact the nearest local
office of the California Fair Employment Practices Commission.
COMPLETE ALL ITEMS - PLEASE PRINT
Proposed Occupants
Birthdate
Proposed Occupants
Birthdate
(1)
(3)
(2)
(4)
PROPOSED OCCUPANT (1)
Name:
Social Security:
Home Phone:
Driver’s License No.:
Address-Number and Street, City, Zip
Owner or Manager
Phone
From
To
Present:
Previous:
Next Previous:
PRESENT EMPLOYMENT
PRIOR EMPLOYMENT
Employer:
Business Address:
Business Phone:
Name/Title of Supervisor:
How Long?
Current Salary:
Weekly $
Monthly $
Or Annual $
Name of
Address:
Chk. Acct. No.: _________________
Bank:
Savgs Acct. No. _________________
Name of
Address:
Chk. Acct. No.: _________________
Bank:
Savgs Acct. No. _________________
FINANCIAL OBLIGATIONS
Payments to:
Address:
Amount:
Payments to:
Address:
Amount:
Payments to:
Address:
Amount:
Vehicle:
Make:
Model
Year:
License No.
State
Vehicle:
Make:
Model
Year:
License No.
State
Vehicle:
Make:
Model
Year:
License No.
State
Will you have any waterbeds? ____________________________________________________________________
Why are you vacating your present place of residence? ________________________________________________
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