Title Page
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Conducted on
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Legal Name
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Location
THE APPLICANT
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Legal Name
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Birth Date
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Address
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School you now attend
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CEEB/ACT Code
SECONDARY SCHOOL COUNSELOR
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What is the primary language of instruction in your secondary school?
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Is promotion within your educational system based upon standard examinations (for example: Abitur, GCSE/A-Level, ICSE/ISC, etc.) given at the end of lower and/or senior secondary school by a state or national examinations board?
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Please attach an official copy of this student’s lower secondary examination results. If the student has already taken senior secondary leaving exams, please include an official copy of the results. If this applicant’s senior secondary leaving exam results are not yet available, please indicate predicted results on the reverse. If you have already forwarded these results with the School Report, you do NOT need to attach another copy to this form.
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Please attach an official transcript of this student’s academic record for the final three years of secondary school, including courses taken and marks/grades in those courses. If you have already forwarded a full transcript with the School Report, you do NOT need to attach another copy to this form.
Senior secondary leaving examinations
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Date of exam (month/year)
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Examining board
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Academic subject
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Predicted result
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Actual result
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Please indicate the marking or grading scale used in your school and its approximate equivalence to the A-F scale commonly used in the United States:
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Counselor’s Name (Mr./Mrs./Ms./Dr.) and Signature
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Title and School
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School Address
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Counselor's Phone and Fax #
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Secondary School CEEB/ACT Code
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Counselor's E-mail
