Print your name in your first language: Test Center Name:

Test Date: SCHOOL USE ONLY

1. NAME: Print your name. Using one box for each letter, first print your Given (first) name, then your Family (last) name.
2. STUDENT NUMBER
Below each box, use a No. 2 pencil and fill in the circle matching the same letter.
Start here
GIVEN (FIRST) NAME FAMILY (LAST) NAME

A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A 0 0 0 0 0 0 0 0 0 0 0 0 0
B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B 1 1 1 1 1 1 1 1 1 1 1 1 1
C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C 2 2 2 2 2 2 2 2 2 2 2 2 2
D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D 3 3 3 3 3 3 3 3 3 3 3 3 3
E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E 4 4 4 4 4 4 4 4 4 4 4 4 4
F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F 5 5 5 5 5 5 5 5 5 5 5 5 5
G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G 6 6 6 6 6 6 6 6 6 6 6 6 6
H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H 7 7 7 7 7 7 7 7 7 7 7 7 7
I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 8 8 8 8 8 8 8 8 8 8 8 8 8
J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J 9 9 9 9 9 9 9 9 9 9 9 9 9
K K K K K K K K K K K K K K K K K K K K K K K K K K K K K K

L L L L L L L L L L L L L L L L L L L L L L L L L L L L L L
3. DATE OF BIRTH 4. GENDER
M M M M M M M M M M M M M M M M M M M M M M M M M M M M M M
Month Day Year
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N BOY
O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O Jan
P P P P P P P P P P P P P P P P P P P P P P P P P P P P P P Feb GIRL
Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Mar 0 0 0 0 0 0
R R R R R R R R R R R R R R R R R R R R R R R R R R R R R R Apr 1 1 1 1 1 1
S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S May 2 2 2 2 2 2
T T T T T T T T T T T T T T T T T T T T T T T T T T T T T T Jun 3 3 3 3 3
U U U U U U U U U U U U U U U U U U U U U U U U U U U U U U Jul 4 4 4 4
V V V V V V V V V V V V V V V V V V V V V V V V V V V V V V Aug 5 5 5 5
W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W Sep 6 6 6 6
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Oct 7 7 7 7
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Nov 8 8 8 8
Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Z Dec 9 9 9 9

5. COUNTRY 6. LANGUAGE 7. 8. 9. 10. GROUP CODE 11. CODE SETS (if assigned)
At my school, I have studied What test(s) have you (if assigned)
CODE CODE CODE SET CODE SET CODE SET
I am in: English for: taken before? 1 2 3

Grade 1 1 year or less TOEFL Primary

Step 1
Grade 2 2 years
0 0 0 0 0 0 Grade 3 3 years TOEFL Primary 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Step 2
1 1 1 1 1 1 Grade 4 4 years 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 Grade 5 5 years Both 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 Grade 6 6 years or more None 3 3 3 3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 Grade 7 4 4 4 4 4 4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 Grade 8 5 5 5 5 5 5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 Grade 9 6 6 6 6 6 6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 Other 7 7 7 7 7 7 7 7 7 7 7 7 7 7
8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8
775600
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

PAGE 1 99524-99524 • Y613E1 • Printed in U.S.A. Q3674/1-2

 Reading
1. A B C 10. A B C 19. A B C

2. A B C 11. A B C 20. A B C

3. A B C 12. A B C 21. A B C

4. A B C 13. A B C 22. A B C

5. A B C 14. A B C 23. A B C

6. A B C 15. A B C 24. A B C

7. A B C 16. A B C 25. A B C

8. A B C 17. A B C

9. A B C 18. A B C

Total correct

Listening
1. A B C 10. A B C 19. A B C

2. A B C 11. A B C 20. A B C

3. A B C 12. A B C 21. A B C

4. A B C 13. A B C 22. A B C

5. A B C 14. A B C 23. A B C

6. A B C 15. A B C 24. A B C

7. A B C 16. A B C 25. A B C

8. A B C 17. A B C 26. A B C

9. A B C 18. A B C 27. A B C

Total correct

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