Glue the top edge of the copies to the reverse of this form here.
3ULQWRXWLQ$&RS\WKHGRFXPHQWVWREHDWWDFKHGLQ$DQGJOXHWKHWRSHGJHRIWKHɻ)RUPIRUVXEPLWWLQJ0HDVOHVDQG5XEHOODFHUWLILFDWHVIURQWRIHDFKFRS\WRWKHUHYHUVHRIWKLVIRUP VHHWKHQH[WSDJHIRUDQ
H[DPSOH

0DOHʀ)HPDOH*HQGHU

1DPH

6WXGHQW,'(PDLO$JH

ɻ7(/)DFXOW\*UDGXDWH6FKRRO$IIOLDWLRQ'HSDUWPHQW'DWHRI%LUWK\HDUPRQWKGD\3OHDVHILOORXWWKLVIRUP\RXUVHOI ,WLVQRWQHFHVVDU\WRKDYHLWILOOHGRXWE\DPHGLFDOLQVWLWXWLRQ 3OHDVHDWWDFKDFRS\RIWKHUHOHYDQWSDJHRI\RXU0RWKHUDQG&KLOG+DQGERRNYDFFLQDWLRQUHFRUGVWHVWUHVXOWVHWFDVSURRI
,IVXEPLWWLQJDFHUWLILFDWHSOHDVHDWWDFKDFRS\DQGNHHSWKHRULJLQDOKDQG\9DFFLQDWLRQUHFRUG

ɻˠ3OHDVHILOOLQWKHYDFFLQDWLRQV\RXKDYHUHFHLYHGDIWHUWKHDJHRI)LUVW9DFFLQDWLRQʕSOHDVHFLUFOH

6HFRQG9DFFLQDWLRQʕSOHDVHFLUFOH:HVWHUQFDOHQGDU

0HDVOHVDORQH:HVWHUQFDOHQGDU

0HDVOHVDORQH

0HDVOHV\HDUPRQWKGD\:HVWHUQFDOHQGDU5XEHOOD

\HDUPRQWKGD\05005
RWKHUV\HDUPRQWKGD\:HVWHUQFDOHQGDU

5XEHOODDORQH

05005
RWKHUV

05005
RWKHUV5XEHOODDORQH\HDUPRQWKGD\05005
RWKHUV&RPPHQWV ,I\RXKDYHUHFHLYHGDPHDVOHVUXEHOODYDFFLQHWLPHVRUPRUHSOHDVHZULWHWKHGHWDLOVLQWKHVSDFHEHORZ

ʴ7KHGRFXPHQWVLQHLWKHURUEHORZDUHUHTXLUHGʵ
ɻᶅɻ'RFXPHQWVFHUWLI\LQJWKDW\RXKDYHEHHQYDFFLQDWHGWZLFHDJDLQVWERWKPHDVOHVDQGUXEHOODDIWHUWKHDJHRI
UHFRPPHQGHG
ɻᶆɻ'RFXPHQWVFHUWLI\LQJWKDW\RXKDYHEHHQYDFFLQDWHGDJDLQVWPHDVOHVDQGUXEHOODRQFHZLWKLQWKHODVW\HDUV
ˠ(YHQLI\RXPHHWWKHUHTXLUHPHQWVLQᶆSOHDVHZULWHLQWKHWDEOHDERYHLI\RXKDYHEHHQYDFFLQDWHGDJDLQVWPHDVOHVUXEHOODWZLFHDQGDWWDFKWKHFHUWLILFDWH V ˠ7KRVHLQWKH)DFXOW\RI0HGLFLQH 'HSDUWPHQWRI0HGLFLQH'HSDUWPHQWRI+HDOWK *UDGXDWH6FKRRORI0HGLFLQHDQG*UDGXDWH6FKRRORI+HDOWK6FLHQFHVPXVWPHHWWKHUHTXLUHPHQWVLQᶅ$QWLERG\WLWHUWHVWUHVXOWV EORRGVDPSOLQJ
ɻ2QO\LIWKHDERYHYDFFLQDWLRQKLVWRU\UHTXLUHPHQWVDUHQRWPHW'RFXPHQWVDUHUHTXLUHGWRFHUWLI\WKDWWKHUHVXOWVRIPHDVOHVDQGUXEHOODDQWLERG\WHVWVWDNHQZLWKLQWKHODVWILYH\HDUVVKRZWKDW\RXKDYHVXIILFLHQWOHYHOVRIDQWLERGLHVLQ\RXUEORRGWRSUHYHQWWKHRQVHWRIPHDVOHVDQGUXEHOOD VHHEHORZ ɻ㻵 㼒 㻌 㼥㼛㼡㼞 㻌 㼢㼍㼏㼏㼕 㼚㼍㼠 㼕 㼛㼚㻌 UHFRUG㻌 㼙㼑㼑㼠 㼟㻌 㼠 㼔㼑㻌 㼞 㼑㼝㼡㼕 㼞 㼑㼙㼑㼚㼠 㼟㻘 㻌 㼥㼛㼡㻌 㼐㼛㻌 㼚㼛㼠 㻌 㼚㼑㼑㼐㻌 㼠 㼛㻌 㼠 㼍㼗㼑㻌 㼠 㼔㼑㻌 㼍㼚㼠 㼕 㼎㼛㼐㼥㻌 㼠 㼑㼟㼠 㼟㻚ɻ9DFFLQDWLRQLVUHTXLUHGLI\RXUDQWLERG\WHVWUHVXOWVDUHEHORZWKHVWDQGDUGYDOXHɻ7KHYDOLGLW\SHULRGIRUWKHDQWLERG\WHVWLVZLWKLQ\HDUVIURPWKHILUVWGD\RIWKHDGPLVVLRQ\HDUɻ$WWDFKDFRS\RIWKHWHVWUHVXOWRUFHUWLILFDWHWKDWFRQWDLQVWKHᶅ6DPSOLQJGDWHɻᶆ0HDVXUHGDQWLERG\WLWHUɻᶇ5HIHUHQFHYDOXHIRUWKH
PHDVXUHPHQWPHWKRG
6DPSOLQJGDWH
0HDVOHV

5XEHOOD:HVWHUQFDOHQGDUɻɻɻɻɻ\HDUPRQWKGD\:HVWHUQFDOHQGDUɻɻɻɻɻ\HDUPRQWKGD\˕FLUFOHWKHPHDVXUHPHQW
PHWKRG,J*(,$ː3$17+,ː
,J*(,$0HDVXUHGDQWLERG\WLWHU*HQHUDOVWDQGDUGV0HGLFDOVWDQGDUGVPRUHWKDQPRUHWKDQPRUHWKDQWLPHVPRUHWKDQWLPHVPRUHWKDQWLPHVPRUHWKDQWLPHVPRUHWKDQWLPHVPRUHWKDQWLPHVPRUHWKDQ

PRUHWKDQɻːɻ,J*(,$LVUHFRPPHQGHGIRUPHDVOHVDQGWKH+,PHWKRGLVUHFRPPHQGHGIRUUXEHOOD 7KHPHDVOHV+,PHWKRGFDQQRWEH
DFFHSWHG
ɻɻ7KH,J*(,$VWDQGDUGYDOXHLVWKHVDPHDVWKHVWDQGDUGYDOXHIRUWKH'HQND6HLNHQNLWZKLFKLVFXUUHQWO\ZLGHO\XVHGLQ-DSDQ
7KHVWDQGDUGVIRUDQWLERG\WHVWVFRQGXFWHGE\RWKHUFRPSDQLHVYDU\VRSOHDVHFKHFNZLWKWKHDGPLQLVWHULQJPHGLFDOLQVWLWXWLRQ,IWKHWHVWLVFRQGXFWHGE\DQRWKHUFRPSDQ\ZHUHFRPPHQGWKDW\RXFKRRVHDGLIIHUHQWPHDVXUHPHQWPHWKRGɻ,I\RXUDQWLERG\WHVWUHVXOWVDUHWRRORZEXW\RXDUHXQDEOHWREHYDFFLQDWHGGXHWR\RXUSK\VLFDOFRQVWLWXWLRQRURWKHUUHDVRQVSOHDVH
ILOOLQWKHIROORZLQJɻ,I\RXKDYHDFHUWLILFDWHSOHDVHDWWDFKDFRS\5HDVRQʁ6XEPLVVLRQVDPSOH

Align the copied documents withthe form, then carefully glue thetop 2cm of the front of eachcopied document to the back ofthe form.

Complete allsections

Read the instructions carefully, fill in
all applicable sections, and makecopies of certificates etc. that containthe information filled out in this form.

Mother and child notebook copy,etc.
Make A4 sized copies and place themunderneath this form with the corners aligned