Name 1 (at time of attendance at Gates Chili)

Name 2 (used for college or employment application, if different)

Date of Birth

Year of Graduation (if withdrawal, use year you would have graduated)

Indicate the type of record you are requesting Official Transcript (MUST send to a school or work place and includes all grades and testing scores) Unofficial Transcript (sent to former student and does not include the testing scores) Health Records (required for college applications in NY, not req. for outside of NY or employment) IEP Psychology Report

College or Employer complete name and address (Official Transcript Request)

Your Complete Address - (Unofficial Transcript Request)

Your Contact Information

Telephone # (including area code)

Email

Additional Comments

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