Please provide the following contact information:  (Required*)

First Name *
Last Name *
Middle Name *
Other/Nick Name
Title (Mr. Mrs...)
Street Address *
Address (cont.)
City *
State/Province *
Zip/Postal Code *
Country *
Work Phone
Home Phone
FAX
E-mail

Please identify and describe yourself:

Date of Birth *
Sex*	Male Female
Height
Weight
Hair Color	Blonde Brown Black Red Gray White
Eye Color	Blue Brown Black Green Gray Violet

Maiden Name

Mother's maiden name

Drivers License Number *

State of Issue *

Social Security Number *

Select One *

Race American Indian African American Hispanic Asian Caucasion White Other

By selecting the submit button I agree to the employer's use of any information provided during the application process in performing the criminal history check.  I understand that I have the right to review and challenge any negative information that would impact my application or employment status.  I understand that I would have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the Rattan School Administration.  By submitting this form I agree that all information is true, correct and complete.  I understand that any information that proves to be incorrect or incomplete would be grounds for canceling my employment applicant status and may be used at the discretion of Rattan Public School District.