Counselor Recommendation Form: Office of Admissions: Indiana University South Bend

Counselor Recommendation and High School Transcript Request Form

Applicant Instructions:

This form is required for currently enrolled high school students in addition to the online undergraduate application for admission. Please complete the applicant information section and submit this form to your high school guidance counselor or principal.

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Applicant Information

LAST NAME:__________________________________________________________________

FIRST NAME:_________________________________________________________________

MIDDLE NAME OR INITIAL____________________________________________________

DATE OF BIRTH (MO/DAY/YR):_________________________

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Counselor or Principal Instructions:

Please complete the remaining sections of this form and forward the completed form and an official high school transcript including SAT or ACT scores if available to the address listed at the bottom of this form. An additional page may be attached if you would like to make any additional comments to assist us in make an appropriate admissions decision.

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Counselor or Principal Information

HIGH SCHOOL NAME:_________________________________________________________

CITY_______________________________________STATE___________ZIP______________

COUNSELOR’S NAME__________________________________________________________

POSITION/TITLE:_____________________________________________________________

TELEPHONE NUMBER:________________________________________________________

EMAIL ADDRESS______________________________________________________________

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Academic Information If Not Included On Transcript

GRADUATION DATE (MO/DAY/YR):___________________

RANK IN CLASS:________SIZE OF CLASS:__________ CUMULATIVE GPA:___________

SAT I VERBAL___________MATH_________TEST DATE (MO/DAY/YR):______________

ACT EN:____MA____RE____SR____CO____TEST DATE (MO/DAY/YR):______________

Indiana Counselors: Please indicate by circling an item if the applicant has completed or is expected to complete:

CORE 40 ACADEMIC HONORS DIPLOMA

21^st CENTURY SCHOLARS PROGRAM GQE QUALIFIER

COMMENTS:

SIGNATURE:______________________________________________DATE:______________

MAIL TO: INDIANA UNIVERSITY SOUTH BEND
OFFICE OF ADMISSIONS
PO BOX 7111
SOUTH BEND, IN 46634