Counselor Information Form

Please print legibly in black ink.

Student: Complete Part I and give this form to your high school guidance counselor or principal to complete. Your application will be

held incomplete until this form is received.

Part I (to be completed by the student)

Student Name: _______________________________________________________________________________________________________________

First/Given

Middle

Last/Family

High School: _____________________________________________________________________________ Date of Birth: _______________________

Address: ________________________________________________ City: ___________________________ State: _______ Zip: __________________

E-mail: ________________________________________________________ IUPUI Online Application Number: ______________________________

If you are currently enrolled in high school, please list your entire senior year schedule. Do not leave this section blank and

do not refer us to your schedule or transcript.

First Semester

Second Semester

_____________________________________________________________________________________________________________________________

Counselor or Principal: If you are able to send the transcript electronically to IUPUI, we prefer that you do so and it is not necessary to

complete this form. Otherwise, please complete the questions below, attach an official copy of the student’s transcript, test scores, and

verify the student’s senior year schedule as listed above. Return this form and the documents to our office.

Part II (to be completed by High School Counselor or Principal)

Applicant ranks ______________ in a class of ______________ Indiana eTranscript Student Testing Number (STN): ______________

Current grade point average ______________ on a (circle scale) 4PT 5PT 6 PT 8PT 10PT 12PT ______________ other scale

Date of graduation (mo/yr): ______ / ______

Your College Board code: __________________________________

SAT I (writing score required): CR: _________ MA: _________ WR: _________ ESSAY: _________ Test date (mo/yr): ______ /______

ACT: EN: _________ MA: _________ RE: _________ SR: _________ CO: _________ WR: _________ Test date (mo/yr): ______ / ______

For Indiana residents only (check if appropriate):

a. Student will receive: c academic honors diploma c Core 40 diploma

b. Has the student passed the ISTEP+ (GQE)? c Yes c No

Counselor name: _________________________________________________ Title:__________________________ Phone:______________________

Counselor e-mail: ____________________________________________________________________________________________________________

Counselor signature:_____________________________________________________________________________ Date:________________________

FEE WAIVER: All student applicants must submit an application fee or request a waiver using a College Board, NACAC, or ACT

Waiver Form. High School counselors may request a fee waiver on school letterhead.

COUNSELOR RECOMMENDATION: Please attach any comments on a separate piece of paper.

Mail this form and all documents to:

IUPUI Office of Undergraduate Admissions

Cavanaugh Hall 147, 425 University Boulevard, Indianapolis, IN 46202-5143

Counselor Information Form - Iupui