PUP-COFO-5-UNRO-031
Rev. 1
June 19, 2019
CONTROL NO.: ______________________
REPUBLIC OF THE PHILIPPINES APPLICATION FOR
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES LATE REPORTING OF GRADE
OFFICE OF THE UNIVERSITY REGISTRAR (Please attach certified photocopy of class record and Official Receipt)
STUDENT RECORDS SERVICES COMPLETION OF "INCOMPLETE GRADES"
STA. MESA, MANILA (Please attach photocopy of Official Receipt)
/ CORRECTION OF ENTRY
(Please attach certified photocopy of class record & Affidavit of Change of Grade)
Others
DATE:
The Dean
College of: ___________________________________________________
I hereby request that
Student Number: ___________________________ Name: ___________________________________________________________
(Example: 2010-000001-MN-0) (Last Name) (First Name) (Middle Name)
Course: __________________________________ Year & Section: ________________________________________
Subject Code: ___________________________________ Subject Title: ________________________________________
School Year: ___________________________________ Term: First Semester
School Session: Day Second Semester
Night Summer Campus: __________________
which was reported as:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
due to the following reason/s:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
be credited as one:
who has "NO GRADE" in the Grade Sheets to a final grade of ______________________ ______________ units.
who has completed all the requirements with a final grade of ______________________ ______________ units.
GRADE: First Grading : _______________Second Grading: ____________ Final Grade : _______________
whose name in the Grade Sheet be corrected
From: _____________________________________________________________________________________
(Last Name) (First Name) (Middle Name)
To: _____________________________________________________________________________________
(Last Name) (First Name) (Middle Name)
Others, specify:
___________________________________________________________________________________________
___________________________________________________________________________________________
Thank you.
___________________________________________________
PROFESSOR/INSTRUCTOR
(Signature over Printed Name)
APPROVED BY DEAN/CHAIRPERSON
Name: _____________________________________________ Signature: __________________________ Date: _____________
Received by Office of the Student Records, University Registrar
Name: _____________________________________________ Signature: __________________________ Date: _____________
Campus: __________________
______________________________________
______________________________________
______________________________________