Form 3: Request Form
(Updated: July 2015) MSU- ILIGAN INSTITUTE OF TECHNOLOGY
OFFICE OF THE REGISTRAR
A. Bonifacio Avenue, Tibanga, 9200 Iligan City Website: [Link]
Telephone Nos: (063) 221-4050 to 55 Local: 4165 Tele/fax: (063) 223-3794 e-mail: registrar@[Link]
Date of Request : June 28, 2017 Date Due:
Remarks:
REQUEST FOR: [one (1) request form per document type]
Part 1:
Authentication ( Cert., TOR, Diploma) Cert. 12.6a: English Units Earned, Alumnus Cert. 12.12: Academic Honors
Evaluation Cert. 12.6b: Education Units Earned, Alumnus Cert. 12.12: Academic Honors with No. of
Diploma Cert. 12.6c: Social Sciences Units Earned, Alumnus Graduates in Respective Program
Reprinting of Lost Diploma Cert. 12.6d: Language Units Earned, Alumnus Cert. 12.13: Valedictorian/Salutatorian
Cert. 12.1a: Current Student (summer) Cert. 12.6e: Liberal Arts Units Earned, Alumnus Cert. 12.14: Grade Equivalency
Cert. 12.1b: Current Student, units earned Cert. 12.6f: Language/Liberal Arts. Social Cert. 12.15: Lost Diploma
Cert. 12.1c: Current Student, GSIS Sciences Units Earned, Alumnus Cert. 12.16: No Objection
Cert. 12.1d: Current Student w/o GPA Cert. 12.6g: English Units Earned with (pls. indicate name of requesting school & address)
Cert. 12.1e: Former Student, units earned General Average, Alumnus
Cert. 12.2: Current Student w/ GPA Cert. 12.6h: English Units Earned with
Cert. 12.3a: Former Student w/ GPA General Average, Student
Cert. 12.3b: Former Student w/o GPA Cert. 12.6i: Field Study (FS) Units Earned
Cert. 12.4a: English as a Medium of with GPA, Student Cert. 12.18: Acceptance Notice
Instruction, student Cert. 12.6j: Field Study (FS) Units Earned with Cert. 12.19: Affirmation on Diploma Reprinting
Cert. 12.4b: English as a Medium of GPA, Alumnus Cert. 12.20: Diploma Correction
Instruction, Alumnus (Undergraduate) Cert. 12.7: Current Student with Subjects Taken Cert. 12.21: Practice Teaching Units Earned
Cert. 12.4c: English as a Medium of Instruction, Cert. 12.8a: Graduating with GPA Cert. with GPA, Alumnus
Alumnus (Graduate & Undergraduate) 12.8b: Graduating without GPA Cert. Cert. 12.22: Practice Teaching Units Earned
Cert. 12.5a: English Units Earned, Student 12.9a: CAR Pending BOR Res. Cert. with GPA, CPRT
Cert. 12.5b: Education Units Earned, Student 12.9b: CAR w/o Thesis/Dissertation Cert. Cert. 12.23: Academic Honors with Ranking
Cert. 12.5c: Education Units Earned 12.10: Graduation w/o GPA Permit to Cross-Enroll
with GPA, Student Cert. 12.11: Graduation with GPA
Cert. 12.5d: Education Units Earned Cert. 12.11A: Graduation with GPA
with GPA, Alumnus & Equivalent Grade
Report of Grades: Semester, AY
COR Reprinting: Semester, AY Others:
nd
Part 2: Transfer Credential (TC) 2 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.: 2011-2639 Student Name: Darwin Dagomboy Velarde Student x Alumnus
Contact No.: +639481883555 e-mail address: darwindvelarde@[Link]
Home Address: 50-A, Bgy. San Miguel, Puerto Princesa City, 5300, Palawan
Mailing Address: 50-A, Bgy. San Miguel, Puerto Princesa City, 5300, Palawan
Degree/Course: BS Biology Major/Option: Botany Honor/Academic Distinction: N/A
nd
Date of Graduation: April 7, 2015 Last Semester & AY of Attendance in IIT: 2 Semester, AY 2015-2016
High School Graduated: Palawan National School
If transferee, last school/university attended: N/A
Purpose of Request: Graduate Scholarship Application
P.2. (For Part 2 document request, please fill entries under P.1 & P.2) Assessment of Fees (to be filled out by Staff):
Sex: Male Date of Birth: April 19, 1994 Religion: Roman Catholic Certification 50
Place of Birth: Puerto Princesa City, Palawan COR Reprinting 20
Citizenship: Filipino Civil Status: Single Report of Grades 20
Spouse (If Married): N/A Authentication (10/page@ pp)
Name of Father: Andres Cangayo Velarde Jr. Evaluation 50
Name of Mother ( Maiden Name): Yvonne Jagmis Dagomboy Reprinting of Lost Diploma 150
Address of Parents: 50-A, Bgy. San Miguel, Puerto Princesa City, 5300, Palawan TOR (50/page @ pp)
Name of Authorized Person: Prof. Christina A. Barazona-Cuevas, M. Sc. Transfer Credential 150
Mailing & Handling (OIS 01) 250
Requested by: Rush Job 60
Total Assessment ---------------------------------- Php
DARWIN D. VELARDE Assessed by:
Signature over Printed Name 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. B