Scribd
Upload
222 views2 pages

Form 3, Request-Form

This document is a request form for various documents from the registrar's office of the MSU-Iligan Institute of Technology. It contains sections for the requester to fill out their personal details and information about their degree. It also lists the various documents that can be requested, including certificates, transcripts, diplomas and other records. There are instructions that the requester or authorized person must present identification and other requirements depending on if they are requesting for themselves or on behalf of someone else. Fees for the different request types are also noted on the form.

Uploaded by

Patrick Go
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
222 views2 pages

Form 3, Request-Form

This document is a request form for various documents from the registrar's office of the MSU-Iligan Institute of Technology. It contains sections for the requester to fill out their personal details and information about their degree. It also lists the various documents that can be requested, including certificates, transcripts, diplomas and other records. There are instructions that the requester or authorized person must present identification and other requirements depending on if they are requesting for themselves or on behalf of someone else. Fees for the different request types are also noted on the form.

Uploaded by

Patrick Go
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 2

Form 3: Request Form

(Updated: July 2013)

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 Tele/fax: (063)223-3794
e-mail: [email protected]

Date of Request

: ______________

Date Due: ________________


Remarks: _________________

REQUEST FOR: [one (1) request form per document]


Part 1:
Authentication (Cert., OTR, Diploma)
Evaluation
Diploma
Diploma Reprinting
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. 12.2: 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

Cert. 12.5a: English Units Earned, Student


Cert. 12.5b: Education Units Earned, Student
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. 12.7: Current Student with Subjects Taken
Cert. 12.8: Graduating with GPA

Report of Grades: ____________________ Semester, SY________________________


COR Reprinting: _____________________ Semester, SY________________________

Part 2: Transfer Credential (TC)


Official Transcript of Records (TOR)

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. 12.12: Academic Honors
Cert. 12.13: Valedictorian/Salutatorian
Cert. 12.14: Grade Equivalency
Cert. 12.15: Lost Diploma
Cert. 12.16: No Objection
Cert. 12.17: Course Description
Cert. 12.18: Acceptance Notice
Permit to cross-enroll

Others: _____________________________

2nd School Request


Certification, Authentication & Verification (CAV)

P.1. (For Part 1 document request, please fill entries under P. 1.)
I.D. No.:_______________ Name: _____________________________________Contact No: __________________e-mail : _______________
Home Address: ___________________________________________________________________________ Student
Alumnus
Mailing Address: ___________________________________________________________________________________________________
Degree/Course: _________________________Major/Option: ______________________Honor/Academic Distinction: __________________
Date of Graduation: ______________________________ Last Semester & SY 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: ___________________________
Place of Birth: ___________________________________________________

Assessment of Fees (to be filled out by Staff):


Certification --------------------------------------

50
Citizenship: ____________________ Civil Status: ______________________

COR Reprinting ---------------------------------

20
Spouse (If Married): ______________________________________________

Report of Grades -------------------------------

Name of Father: _________________________________________________

20
Authentication (10/page@ ___pp) ---------

Name of Mother (Maiden Name): _____________________________________


50
Name of Authorized Person: ________________________________________

Evaluation

----------------------------------------

Diploma Reprinting ---------------------------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

___ pc/s Long Brown Envelope/s

Reminder:

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 CHED 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.

You might also like