ASSOCIATION OF MINEMEN
HIGH SCHOOL AND COLLEGE TRANSCRIPT
AOM Form S-2

                                                PRIVACY ACT STATEMENT
Authority to request this information derived   from  the United States Code  301. Departmental  Regulations. Purpose of the request is to obtain information about academic performance of applicant and will be used by AOM scholarship committee  to evaluate applicant's  academic achievement.  Applicant release of transcript data : failure to do so may result in delay, improper  processing, or disqualification of the applicant participation in the AOM scholarship program.

The below named high school/college has my permission to release my official transcript  to  AOM scholarship  committee.

                                                                                               _________________________________________
   (Signature of Student)

 

                                                         INSTRUCTIONS
High school/ college officials are requested to complete This form, attach  a copy of  the   students   official transcript, including grades achieved, and forward to  the AOM scholarship committee. Transcripts most he received on / before I May of each scholarship year.

Mail  to: Association of Minemen, Scholarship Committee,  PO Box 510519, Punta Gorda, FL 33951               

Provide the following information even if given in transcript:

Students  Name ( last, first, middle) ________________________________________________________

Students address ________________________________________________________________________

Name and address at high school or college _________________________________________________ 

High school or College accredited__________________________________________________________ 

Students dates of attendance ______________________________________________________________ 

 

FROM:

TO:

Commulative grade point average (high school / college: circle whichever is applicable

College Entrance Test Scores (use CEEB / Sat or ACT scores only)

CEEB / Sat Verbal

CEEB / Sat Math

Date of Test

ACT Composite

Date of Test

High school Class Size

High School Class Rank

These must be completed and may be based on the most recent information available if final results are not completed. if ranks are not used, percentage must be estimated.

Remarks by counselors or teachers that may be beneficial to the scholarship committee

Type name of school official

Title

Signature of school official

Date