Residential Rental Application Page 3
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RESIDENTIAL RENTAL APPLICATION (Cont’d)
RW 11-5 (Rev. 6/99)
PROPOSED OCCUPANT (2) — — — — Continued
Father’s
Mother’s
Name:
Name:
In Case of Emergency,
Address:
Notify:
Number / Street / City /, State /, ZIP Code
Phone
Relationship
(1)
Personal
Length of
Address:
Reference:
Number / Street / City /, State /, ZIP Code
Phone
Occupation
Acquaintance
(1)
(2)
Applicant represents that statements above are true and correct and hereby authorizes verification of references including,
but not limited to, the obtaining of a credit report and agrees to furnish additional credit references upon request. Applicant
acknowledges receipt of notification of the relevant provisions of the Federal Privacy Act of 1974.
The undersigned makes application to rent State of California, Department of Transportation property and, upon approval
of this application, agrees to sign a rental or lease agreement and to pay all sums due before occupancy.
RENTAL RATES YOU ARE INTERESTED IN $______________________ to $ _________________________
NUMBER OF BEDROOMS REQUIRED: ________________
AREA IN WHICH YOU WISH TO BE LOCATED: COUNTY __________________
CITY ___________________
ADDRESS(ES) OF STATE-OWNED PROPERTY(IES) YOU ARE INTERESTED IN:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
TYPE OF PROPERTY:
[ ] Single Family Residence
[ ] Industrial
[ ] Commercial
[ ] Apartment
[ ] Agricultural
[ ] Other: _________________________________
_____________________________ ________________ _____________________________ _________________
Signature
Date
Signature
Date
INFORMATION COLLECTION AND ACCESS
The Information Practices Act of 1977 (Civil Code Section 1798 et seq.) requires the following information to be provided
when collecting information from individuals.
AGENCY NAME:
Name, Title, Address, and Telephone Number of Official Responsible for Information Maintenance
Authority for the maintenance of information:
Streets and Highways Code Section 104.6
Caltrans Right of Way Manual, Section ________________
State Administrative Manual, Sections 8072.3, 8790.7 and 10510 and Government Code Section 12419.5
The disclosure of all items of information requested is mandatory in that this Rental Application will not be processed if
any portion of the requested information is not provided.
The information provided in this form will be used by the Department of Transportation to determine the suitability of the
applicant to rent.
All applicants have the right of review files containing personal information that are kept on them by the Department of
Transportation. Upon request and proper identification, applicants may inspect all personal information contained in any
record maintained on them during the regular business hours of the Department.
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