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HASBROUCK HEIGHTS BOARD OF EDUCATION
Hasbrouck Heights, New Jersey  07604       File Code:  5118 
Exhibit

APPLICATION FOR RESIDENCY INVESTIGATION

SUSPECTED NON-RESIDENT’S INFORMATION

EVIDENCE OF NON-RESIDENCE (check all that apply)
                 Witnessed students being transported in or out of town
                 Know actual residents at the claimed Hasbrouck Heights address
                 Know family moved from the claimed Hasbrouck Heights address
                 Other (specify):                                                                                                        
                                                                                                                                                   
                                                                                                                                                    

CERTIFICATION STATEMENT

I understand that the information provided will remain confidential to the extent allowed by law.  I certify that I am not an employee of the Hasbrouck Heights Board of Education, or family member of an employee, and have not received this information from a member of the school staff.  I may be entitled to all or partial payment, depending on how many people provided information leading to the identification of this non-resident.

Signature___________________________________Phone Number____________________________

Name (please print)___________________________________Date Presented___________________

*Reward $250.00

* If evidence results in the student’s being removed from school.