SHAKER HIGH SCHOOL
Latham, New York
Student Operator (Last Name, First Name): ________________________________________________
Homeroom Number: _______
School Year (Circle One): 11 12
Home Address: _______________________________________________________________________
Home Telephone Number: _______________________
Year and Make of Vehicle: ________________________________________________
Color: _______________________
Vehicle License Plate Number: _______________________
List all moving violations: _______________________________________________________________________
If currently employed, please complete the following:
Name of Employer: ________________________________________________
Telephone number: _______________________
Address of Employer: _______________________________________________________________________
Name of Manager or Supervisor: ________________________________________________
Reporting Time to Work: _______ P.M.
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Student Information Verified by: ________________________________________________
Date of Verification: _______
Student Parking Permit Number: _______