Grade Report Form - 2016
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1SECTION 1:
Personal Data: To be completed by the applicant
Social Security Number ______/____/________
Last Name_____________________________________First Name _________________ MI___________
Address _______________________________________________________________________________
Number and Street/Route Number and/or Box Number
City________________________State___________________ Zip _______________________________
I, the undersigned, do hereby authorize the release of my secondary academic performance record
to the West Virginia Higher Education Policy Commission
Applicant Signature_____________________________________ Date_________________
Parent Signature________________________________________ Date_________________
SECTION 2:
To be completed by school official: This section is applicable ONLY to
High School Data
high school graduates who have not completed any college hours after
and Test Scores
high school graduation.
Please complete the following information for the above applicant and attach a current transcript.
Both the overall gpa and core gpa must be submitted to determine eligibility.
____________________________________________________________________________________
Name of High School
High School Code Number
____________________________________________________________________________________
Date of High School Graduation
High School Overall Grade Point Average
_______________________________________ _________________________________________
Student ID/WVEIS Number
High School Core Grade Point Average
ACT
SAT
SAT ID (if applicable)
ACT ID (if applicable)
Test Date:
Test Date:
MM/YY
MM/YY
English
Verbal
Math
Reading/Soc. Sci.
Math
Sci. Reas/ N. Sci.
Total
Composite
SECTION 3:
Official Signature: To be completed by the school official:
____________________________________________________________________________________
School Official’s Signature
Date Completed by School Official
Please attach transcript and return to:
Office of Financial Aid and Outreach Services
West Virginia Higher Education Policy Commission
1018 Kanawha Boulevard, East, Suite 700
Charleston, West Virginia 25301
Phone 304.558.4614
Fax 304.558.4622
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