Hardcopy form

Student Recommendation Data Form
Gary Jaye

INSTRUCTIONS:
1. Print this form from your browser on a single sheet of paper (using both sides if necessary).
2. Print all the requested data clearly, sign and date the waiver.
3. Return this form tomorrow. During the holiday: Submit by email.

Last name: First name: Middle name:

Official class: Official class room: Applying for early action/decision? (Y/N):

Street Address: Apt number:

City: State: Zip:

Home phone: ( ) Phone during holiday: ( )

Preferred Email address: Other email address:

I agree to waive the right to read the recommendation for which this data form has been completed.

SIGNATURE: DATE:

MATH, COMPUTER SCIENCE, CHEM, AND PHYSICS COURSES* *Add electives like AP Calculus, AP Stat, Introductory Comp Sci, etc...
COURSE	COURSE GRADE	SEMESTER TAKEN	TEACHER	COURSE	COURSE GRADE	SEMESTER TAKEN	TEACHER
EXAMPLE	93	fall 1999	Mr. G. Jaye	CHEM 1
MQ3				CHEM 2
MQ4				PHYSICS 1
MQ5				PHYSICS 2
MQ6				MPX3
ME81				MPX4
ME82				MC1M
MEAA				MCX1
MEAB				MCX2

CURRENT MATH, COMPUTER SCIENCE, CHEM, AND PHYSICS COURSES (Fill this out only if you haven't received your final grades)
COURSE NAME (NOT CODE)	CURRENT GRADE OR AVERAGE	TEACHER

Summer programs and math or science projects:

College majors that you are considering (and why):

Organizations and extra-curricular activities:

Awards and honors:

Old fax number 801-858-7260 no longer works.

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