Date_______________________
Name of Pc_________________________________
Last Grade attained___________________________
Pc’s statement _________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
TA ___________________________
STATE OF NEEDLE_________________________
EXAMINER ROUTES:To C/S___________________
To MO___________________
Back to Post___________________
______________________________________
Signature of Examiner
[This HCO PL was revised by HCO PL 30 September 1968, Issue II, Examiner’s Form, which added blanks for the following text: “Qual Div (place)”, “Time” and, after “Last Grade attained”, “(or) Grade being attested”. It also added two boxes labeled “Before Session” and “After Session”. This PL was then revised by HCO PL 9 May 1969, which was revised and replaced by HCO PL 26 January 1970, Issue III, both titled Examiner’s Form, neither of which were written by LRH. These were revised by HCO PL 8 March 1971, Examiner’s Form which is printed in Volume VII, page 193]