Student Information Sheet Student: ____________________________ Address: _________________________________

Class: ______________________ Hour: ________________________

_____________________________________________

Telephone Number: (___)_________

Book Condition Report Textbook Number:_________ Condition of Textbook: _____ Excellent _____ Good _____ Fair _____ Poor

Please look through your textbook thoroughly and note all damages below. Pay particular attention to the condition of the cover and binding, torn or missing pages, writing in the textbook, stains or dirt, etc. Be specific in noting all damages. Any damage to the textbook not listed below will be charged to you at the end of the year. Then read the statement at the bottom of the page and sign this form, accepting the condition of the textbook as noted below. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I have carefully examined my textbook and have accurately listed all damages to it. I understand that I will be charged for damages to this book beyond those listed here. I accept responsibility for the use and care of this book for the duration of this school year.

Signature:____________________________________________ Date:___________________