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_______ Date of Birth ____________________ Sex M / F City ___________________ State _____ Zip Code _________ Year Student Entered Grade 9 _______________ Phone No. (______) _____________________ ext. _______ Date of Completion of Coursework ____________ Email Address ______________________________________ _________________________________________ Signature of Primary Homeschool Teacher Cumulative GPA ___________ TITLE OF SUBJECT YEAR CREDIT EARNED Updated 08/07 GRADE RECEIVED HRS. OF .

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