NOBLESVILLE SCHOOLS BOOK RENTAL CONTRACT
2016-17 SCHOOL YEAR
FORM 522 (1-8)
School
APPLICATION INFORMATION MUST BE COMPLETE
If no phone, list name and number of relative or close friend
Father’s Name:
Father’s
______________________________________
Father’s Home Phone:________________
Address:________________________________________________________________________
City__________________________________ State_______________
Father’s Employer:
______________________________________
Father’s Social Security #: ___________________________
Mother’s Name: _____________________________________
Zip Code_____________________
Work Phone:____________________
Father’s Birthdate:_____________________
Mother’s Home Phone:________________
Mother’s Address:________________________________________________________________________
City__________________________________ State_______________
Mother’s Employer:
____________________________________
Mother’s Social Security #: _____________________________
Zip Code_____________________
Work Phone:______________________
Mother’s Birthdate:__________________
List below the names and grades for each of your children in this school:
(a form needs to be completed for each individual school)
Grade:_________________
1.Name: ______________________________________________
2.Name: ____________________________________________
Grade:_________________
3.Name: ______________________________________________
Grade:_________________
If there are more than three school aged children in this school, check this box and then list their name(s) and grade
level on the reverse side. [ ]
AGREEMENT
I, as a Noblesville parent and or guardian of the above-named children, owe $___________ in book rental to
_________________________________ school. I agree to pay one-fourth of this balance by October 24, 2016, one-fourth
by November 21, 2016, one-fourth by December 19, 2016 and the final one-fourth by January 16, 2017. Payments shall be made
at the school. Failure to pay all book rental by January 16, 2017 will result in this account being turned over to a collection
agency for collection and the added expense of collection fees and/or court costs will be added to the account.
______________________________
Signature of Parent/Guardian
09/2016
________ ________
Date Agreement
Signed
_______________________
Principal/Designee