4672948520

PAPER-BASED TEST _Tnrr, EXAMINEE'S / UfcrL. SCORE RECORD

JEMIELNIAK-DARIUSZ

4115934 JEM I EL

TEST OF EMGLISH AS A FOREIGN LANOUAGE

~wr		n$r	EEB
SECTION 1	SECTION 2	SECTION 3	TOTAL SCORE
TOEFL SCALĘ SCORES
iU TEST OF WRITTEN EMGLISH« :
			TWE SCORE

EXAMINEE'S ADDRESS:

REGISTRATION NUMBER

NAME (Famlfy or Sumame, Glven. Mlddfe)

MAY 04 Month Year TEST DATĘ	2326 XXXX XXXX XXXX INST. CODĘ	99 XX XX XX m	03/17/75 MoMh'Day/Y»«r DATĘ OF BIRTM			M SEX
			POLAND NATIV£ COUNTRY
P205 CENTER _NJMBEB_
	2326 SPONSOR CODĘ		POLISH NATiyELANG		UAGE
			2 DEGREF.	6 REASON FOR TAK ING TOEFL	0 mik BEFORE

23057 P205 4115934 JEMIELNIAK-DARIUSZ ALUZYJNA 33D/609

U.

yoiw sioNArune

MAMĘ OF COUNTRY ■SSUlNG PASSPORY .. OR IDENTIFICATION ' ^v

WARSZAWA

POLAND

03-149

NUMBER ON IOENT1-FICAnONDOajWEW

Thii documant tontnln* »«tutlfy F«*tur*s, such m vi*lbla flbsrs and a wsUrmark.

Before completing the Score Report Request Form, read the directions on the back.

TOEFL

SCORE REPORT REQUEST FORM

- (INCLUDES TWE SCOREI -

Scores morę than two yeara ol<l eannot bo reported or verified. _(Do not uss thls form a Ker June 30, 2004.)

Cłiock if paylng by Q Amtflenn Erprsw □DI*covpr O JCB

0Ma*t«rOini    Qvisa

and anter your cnrd numbor and »xpir»1lon data

CK*ck tha apprcpriata box to show tha number of raport* you sra requs*ting.

Mallrd Iwo wanks ofiar racatpt of rstąiMłl by TOEFL, or aftłr stora* batom*

»v nl labie

Amoun! Duo in U5 DoMnri* 12    3    4

□ □ □ □ $15 $30 $45 $60 5 fi 7    8

□ □ □ □

$75 $00 $105 $120

Cradlt Cnrd E*plr*tlon Data C

In Csnnds. ndd GST/HST fRa*. No. 131414468 RTl nnd Q3T (Rs^ No 1087987345) to lolnl remlttanee.

4115934	JEMIELNIAK-DARIUSZ	03/17/75	MAY 04	P205	ETS USE ONLY
REGISTRATION NUMBER	NAME: Family name (sumame). glven namo. mlddlo name	Month/Day/Year DATĘ OF BIRTH	Month Year TEST DATĘ	CENTER NUMBER

INSTITUTION

ADDRESS

INSTITUTION

CODĘ

NAME OF DEPARTMENT

DEPT.

CODĘ

DATĘ

I authorlre ETS 1o release my TOEFL and TWE scores. under the condillons set forth In the Information nollclin. 1o 1he Instltutlons deslgnaled above. YOUR SIGNATURE

If your malllng addrnss has changed sińce the test dale indicated above, prlnt your namo and new address in the boxes provided. Uso Engllsh lettors. Leavo a blank box after each complete number or word. leavo blank if there aro no changes.

NAME

MAILING

OR

STREET

ADDRESS

CITY,

STATE, OR PROYINCE

Prlnt yourfamlly name (surnamo), glv«n name. then mlddlo name If you have one Leava a blank box bctween namcs.

2IP/POSTAL CODĘ

COUNTRY

JOtl