Form 3: Request Form
(Updated: May 2015) MSU- ILIGAN INSTITUTE OF TECHNOLOGY
OFFICE OF THE REGISTRAR
A. Bonifacio Avenue, Tibanga, 9200 Iligan City Website: http://www.msuiit.edu.ph
Telephone Nos: (063) 221-4050 to 55 Local: 4165 Tele/fax: (063) 223-3794 e-mail: [email protected]
Date of Request : ______________ Date Due: ________________
Remarks: _________________
REQUEST FOR: [one (1) request form per document type]
Part 1:
Authentication ( Cert., TOR, Diploma) Evaluation
Diploma Reprinting of Lost Diploma
Cert. 12.1a: Current Student (summer) Cert. 12.1b: Current Student, units earned Cert. 12.1c: Current Student, GSIS Cert. 12.1d: Current Student w/o GPA Cert. 12.1e: Former Student, units earned Cert. 12.2: Current Student w/ GPA Cert. 12.3a: Former Student w/ GPA Cert. 12.3b: Former Student w/o GPA
Cert. 12.4a: English as a Medium of Instruction, student Cert. 12.4b: English as a Medium of Instruction, Alumnus (Undergraduate)
Cert. 12.4c: English as a Medium of Instruction, Alumnus (Graduate & Undergraduate)
Cert. 12.5a: English Units Earned, Student Cert. 12.5b: Education Units Earned, Student Cert. 12.5c: Education Units Earned with GPA, Student
Cert. 12.5d: Education Units Earned with GPA, Alumnus Cert. 12.6a: English Units Earned, Alumnus Cert. 12.6b: Education Units Earned, Alumnus Cert. 12.6c: Social Sciences Units Earned, Alumnus Cert. 12.6d: Language Units Earned, Alumnus Cert. 12.6e: Liberal Arts Units Earned, Alumnus Cert. 12.6f: Language/Liberal Arts. Social Sciences Units Earned, Alumnus
Cert. 12.6g: English Units Earned with General Average, Alumnus
Cert. 12.6h: English Units Earned with General Average, Student
Cert. 12.6i: Field Study (FS) Units Earned with GPA, Student
Cert. 12.6j: Field Study (FS) Units Earned with GPA, Alumnus
Cert. 12.7: Current Student with Subjects Taken Cert. 12.8a: Graduating with GPA
Cert. 12.8b: Graduating without GPA Cert. 12.9a: CAR Pending BOR Res.
Cert. 12.9b: CAR w/o Thesis/Dissertation Cert. 12.10: Graduation w/o GPA Cert. 12.11: Graduation with GPA
Cert. 12.11A: Graduation with GPA & Equivalent Grade Cert. 12.12: Academic Honors
Cert. 12.13: Valedictorian/Salutatorian Cert. 12.14: Grade Equivalency Cert. 12.15: Lost Diploma Cert. 12.16: No Objection
(pls. indicate name of requesting school & address)
______________________________
______________________________
Cert. 12.18: Acceptance Notice
Cert. 12.19: Affirmation on Diploma Reprinting Cert. 12.20: Diploma Correction
Cert. 12.21: Practice Teaching Units Earned with GPA, Alumnus Cert. 12.22: Practice Teaching Units Earned with GPA, CPRT
Cert. 12.23: Academic Honors with Ranking Permit to Cross-Enroll
Report of Grades: ____________________ Semester, AY________________________
COR Reprinting: _____________________ Semester, AY________________________ Others: _____________________________
Part 2: Transfer Credential (TC) 2nd School Request
Transcript of Records (TOR) Certification, Authentication & Verification (CAV)
P.1. (For Part 1 document request, please fill entries under P. 1.)
I.D. No.: ________________________ Student Name: ___________________________________________________ Student Alumnus Contact No.: __________________________________________ e-mail : ______________________________________________________
Home Address: _____________________________________________________________________________________________________
Mailing Address: ___________________________________________________________________________________________________
Degree/Course: _________________________Major/Option: ______________________Honor/Academic Distinction: ___________________
Date of Graduation: ______________________________ Last Semester & AY of Attendance in IIT: _________________________________
High School Graduated: ______________________________________________________________________________________________
If transferee, last school/university attended: ______________________________________________________________________________
Purpose of Request: ________________________________________________________________________________________________
P.2. (For Part 2 document request, please fill entries under P.1 & P.2)
Sex: _______ Date of Birth: _______________ Religion: ___________________ 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 Address of Parents: ________________________________________________ Reprinting of Lost Diploma --- 150 Name of Authorized Person: _________________________________________ TOR (50/page @ ___pp) ---
Transfer Credential --- 150
Requested by: Mailing & Handling (OIS 01) --- 250
Rush Job --- 60
---
__________________________________________________
Signature over Printed Name Total Assessment --- Php ____
Assessed by: ___________________________
Other Requirements: Clearance
___ pc/s Documentary Stamp/s
Reminder: ___ pc/s Long Brown Envelope/s
A. If requested by the person himself/herself named in the document, a valid Identification (ID) card must be presented.
B. If requested by an authorized person, the following items must be presented:
Authorization letter (Duly notarized authorization letter for CAV request);
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 person.
