Tutor Application Form

Name of Tutor:* Home Phone:* Cell Phone: Email Address:* State Licensed?* Yes   No Address1:* Address2: City* State* AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT ND NE NH NJ NM NV NY OH OK ON OR PA PE RI SC SD SK TN TX UT VA VI VT WA WI WY Zip Code* How did you hear about us?* Friend Family Member Yellow Pages Google Search MSN Search Other Internet Search Radio TV Newspaper Ad Parent Magazine Other Education/Background (indicate name of school/location and yrs completed) College: Degree(s): Other areas of study: Do you have any special skills or training that will aid in the development of our students?   Yes   No If yes, explain: What Grades/Subjects?

Official background information
Have you ever been convicted of any crime, whether a misdemeanor or felony?*	Yes   No
If yes, when, where and for what crime?
Will you submit to a drug and background test if necessary? *	Yes   No
Do you agree to a background investigation including a criminal background investigation?*	Yes   No
When was your last background check performed?
Date:
By whom:

Tutor Subjects
General Subjects Computer Training English Foreign Language Learning Disabilities Math Music Other (specify in comments) Science Study/Organizational Skills

Would you be interested in putting a Trusted Tutors Magnet on you vehicle for an additional fee?

Yes No

I certify that the information I have provided on all the pages above is true, accurate and correct:
Signature	Date