Form 3: Request Form
(Updated: April 2012)
MSU- ILIGAN INSTITUTE OF TECHNOLOGY
OFFICE OF THE REGISTRAR
A. Bonifacio Avenue, Tibanga Highway, Iligan City 9200 website: http://www.msuiit.edu.ph
Telephone Nos: (063) 221-4050 to 55 Local: 178 or 4165 Telefax: (063)223-3794 e-mail:
[email protected]Date of Request
: ______________
Request Received by: ______________
Date Due: ________________
Remarks: _________________
Date Claimed: ______________
REQUEST FOR: [one (1) request form per document]
Part 1 :
Authentication ( Cert., OTR, Diploma)
Cert. 12.3: Former Student
Cert. 12.8: Graduating with GPA
Evaluation
Diploma
Cert. 12.4: English as a Medium of Instruction
Cert. 12.9: Completed Acad. Requirements
Cert. 12.5: English Units Earned, Student
Cert. 12.10: Graduation w/o GPA
Cert. 12.1: Current Student w/o GPA
Cert. 12.2: Current Student w/ GPA
Cert. 12.6: English Units Earned, Alumnus
Cert. 12.7: Current Student with Subjects Taken
Cert. 12.11: Graduation with GPA
Cert. 12.12: Academic Honors
Report of Grades: ______ Semester, SY_________________
COR Reprinting : ______Semester, SY_________________
Permit to cross-enrol
Others: ___________________________________________
Part 2:
Cert. 12.13: Valedictorian/Salutatorian
Cert. 12.14: Grade Equivalency
Cert. 12.15: Lost Diploma
Transfer Credential (TC)
Official Transcript of Records (OTR)
Certification, Authentication & Verification (CAV)
Direction 1: For part 1 document request, please fill entries under P. 1.
Direction 2: For part 2 document request, please fill entries under P.1 & P.2.
P.1. -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------I.D. No.:__________ Name: _____________________________Contact No: ____________ e-mail address: ____________________
Home Address: __________________________________________________________________
Student
Alumnus
Honor/Academic Distinction: _____________________ Date of Graduation: __________________ Degree/Course: ______________
Major/Option: _________________________________ Last Semester & SY of Attendance in IIT: _____________________________
Purpose of Request:___________________________________________________________________________________________
P.2. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------Sex: ____________________ Date of Birth: ___________________________
Assessment of Fees (to be filled out by Staff):
Place of Birth: ___________________________________________________
Certification --------------------------------- 50
Citizenship: ____________________ Civil Status: ______________________
COR Reprinting ---------------------------- 20
Spouse (If Married): ______________________________________________
Report of Grades -------------------------- 20
Name of Father: _________________________________________________
Authentication (10/page@ ___pp) --Name of Mother (Maiden Name): _____________________________________
Evaluation ----------------------------------- 50
School Last Attended: _____________________________________________
TOR (50/page @ ___pp) --------------Transfer Credential --------------------- 150
Requested by:
Rush Job ---------------------------------- 60
------------------
Total Assessment -------------------- Php ___
_____________________________________
Signature over Printed Name
Assessed by: ________________________
Other Requirements:
Checklist for the release of requested document/s:
A. If claimed by the alumnus/student himself/herself, a valid Identification (ID) card must be presented:
B. If claimed by an authorized representative, the following items must be presented:
authorization letter;
Xerox copy of at least 2 (two) valid Identification (ID) cards of the authorizing person (owner); and
Original & valid Identification (ID) card of the authorized representative.
Clearance
___ pc/s Documentary Stamp/s
___ pc/s Long Brown Envelope/s
