Transcript Request Form (Fee $15.00/$25.00)

Print out and mail to: COPE Testing Ltd. 7B Pleasant Boulevard, Box 957, Toronto, Ontario, M4T 1K2
(Note: this is a mailing address only)

Family name:	Given names:
Title:                                  (Mr. / Mrs. / Ms. / Dr.)	Gender:                              (M/F)
Home telephone number (including area code):
Date of Birth:                                  /               /               (YYYY/MM/DD) year / month / day
E-mail address (if available):
Street Address:
Suite:	City:
Province:	Postal Code:

DATE OF TEST:____________________________________                    REGISTRATION NUMBER: _____________________________

Transcript Request(s) for  your Home Address or the University of Toronto (fee: $15.00 each)
__ Home Address	__ Admissions & Awards, University of Toronto
__ Any other department of the University of Toronto:	Contact Person & Department:
Mailing Address:

Transcript Request(s) for any other institutions (fee $25.00 each transcript)
Name of University:	Contact Person & Department:
Mailing Address:
Name of University:		Contact Person & Department:
Mailing Address:
Credit Card details: Expiry date ______________ (Month/Year)  Amount paid ______________ VISA []   MASTERCARD [] __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Name of Cardholder ______________________ Signature of Cardholder ______________________