CITIZENS APPEAL FORM
*LEVEL I

_____________________ COUNTY SCHOOLS

*This form is to be completed only after an informal conference with the principal or administrator in charge. The appeal procedure approved by the West Virginia Board of Education should be reviewed prior to submitting a formal appeal. Copies are available at the Office of the State Superintendent of Schools, the office of the county board of education and at each public school.
CITIZEN(S) APPEAL
______________________________
Name		 ______________________________
Address		 ______________________________
Phone
______________________________
Name		 ______________________________
Address		 ______________________________
Phone
(Note: If more than two citizens are filing the appeal, the names, addresses and signatures are to be given on the reverse side of (attachment to) this form.)
INFORMATION REGARDING APPEAL

"An 'appeal' is a claim by one or more citizens of a violation of state law or the policies, rules and regulations of the West Virginia Board of Education."

Please identify the state law or policy, rule or regulation of the State Board of Education claimed to have been violated:

In the space provided below briefly describe the problem or concern, how it affects you, and how you think it should be corrected. (Additional information may be attached.).

______________________________
Date		 ______________________________
Signature(s)

Additional Aggrieved Citizens
1. _______________________________________________
Name		 ______________________________
Phone
__________________________________________________
Address		 ______________________________
Signature
2. _______________________________________________
Name		 ______________________________
Phone
__________________________________________________
Address		 ______________________________
Signature
3. _______________________________________________
Name		 ______________________________
Phone
__________________________________________________
Address		 ______________________________
Signature
4. _______________________________________________
Name		 ______________________________
Phone
__________________________________________________
Address		 ______________________________
Signature
5. _______________________________________________
Name		 ______________________________
Phone
__________________________________________________
Address		 ______________________________
Signature
6. _______________________________________________
Name		 ______________________________
Phone
__________________________________________________
Address		 ______________________________
Signature
7. _______________________________________________
Name		 ______________________________
Phone
__________________________________________________
Address		 ______________________________
Signature

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