PG PROFESSIONAL CHILDREN'S SCHOOL Please include $40 non-refundable Application Fee. Admission as not completed until the applicant has been accepted by the School and an enrollment contract has been signed by both the parent and the school. All sections must be fully completed (section S, if applicable). Please print or type. SECTION A. SECTION B. Grades/dates attended Reason for leaving /II sr.:auto En-DEP Vr-rner Date 4725 —"T f 1 tem. 19'1 cnnt... GOVERNMENT EXHIBIT 761 S2 20 O' 330 (a ,0 PCS0000020 EFTA00016517

SECTION C. SECTION D. Required for students who live away from home. Guardian's Guardian's Telephone name Name of business address Business address Business telephone Fax Relationship Occupation/position to student SECTION Who has financial Address 95-7- E. responsibility? tot r • "TeRre Eps+e Madison Ave.. City/state/zipNew ItOr• N P7027 Bank reference (name and branch) J.P. Minttin ) St" ilvt• Do you expect to apply for financial assistance? [ ] Yes '14] No SECTION K Other children in famil PCS0000021 EFTA00016518

SECTION G. Have you any relatives who attended PCS? No Name Relationship Class (if known) SECTION H. How did you become interested in PCS? (List name and address if applicable.) SECTION I. Student History Does the student have an illness or disability which would limit his/her school activities? ( ] Yes X] No Please explain. Has student's school attendance been interrupted for a period of a month or more due to medical reasons? [ I Yes (] No Please give reasons and approximate dates. circumstances. Has the candidate ever attended summer school? ] Yes NI No Give the name and address of the school, the subjects taken, and the reasons for attending. Has the candidate had special tutoring? [ ] Yes 0(] No Please indicate the subject(s), the grade(s), when the candidate was tutored, and the circumstances. Describe any special circumstances which have affected the candidate's performance in school (for example, learning • disabilities, illness, physical handicaps, or frequent changes of home or schools). — NoNE — PCS0000022 EFTA00016519

SECTION J. If the student is "Professional" or "Pre-Professional," please fill out this section. activities generally accorded or made available to students at the School. It does notdiscriminateonthebasisof color, religion. sex or national and ethnicorigin in administration of its educational policies, scholarship and loan programs, orathictic and other school administered programs Please mall this form to: Director of Admissions, Professional Children's School, 192 West 60th Street, New York, N.Y. 10023. Thank you. PCS0000023 EFTA00016520