Application for Home Rental - Town of Samoa, California

Pacific Management

Application for Home Rental

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Home Rental Application

Facility Rules and Regulations

A printable application for home rental is available here. When you see the printable application, please click on the Print button in your web browser to print it. Note that Adobe Acrobat Reader version 4.0 or higher must be installed on your computer. Please fax your completed application to (707) 822-9596 or mail it to 5251 Ericson Way, Arcata, CA 95521.

You also have the option of submitting your application online by using the form below. Please remember that each person 18 years or older who will be residing in the unit must complete an individual application.

Property:

Applicant Name (First, Middle, Last):

Date of Birth:
S.S.N.:
Driver's Lic # State Expiration

Current Address (Number, Street, City, State, Zip):

Telephone #:
Occupancy Dates:
Current Landlord: Telephone #:
Reason for leaving:

Prior Address (Number, Street, City, State, Zip):

Occupancy Dates:
Prior Landlord: Telephone #:

Current Employer:
Company Name: Telephone #:
Monthly Wage: $ Start Date:
Job Title:

Vehicle(s):
Make/Model: Year:
License Plate: Color:

Make/Model: Year:
License Plate: Color:

Nearest Relative (Emergency Contact):
Name:
Address (Number, Street, City, State, Zip):

Relationship to Applicant: Telephone #:

Occupants:
Name: Relationship: Age:
Name: Relationship: Age:
Name: Relationship: Age:
Name: Relationship: Age:
Name: Relationship: Age:

Pets:
Type: Weight: Name:
Type: Weight: Name:
Type: Weight: Name:

I declare that the foregoing is true and correct, authorize its verification and the obtaining of a credit report.