Form 3: Request Form

(Updated: April 17, 2017) 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) Cert. 12.6a: English Units Earned, Alumnus Cert. 12.12A: Academic Honors with No. of
Evaluation Cert. 12.6b: Education Units Earned, Alumnus Graduates in Respective Program
Diploma Cert. 12.6c: Social Science Subjects and Units Earned, Cert. 12.13: Valedictorian/Salutatorian
Reprinting of Lost Diploma With GPA, Alumnus Cert. 12.14: Grade Equivalency
Cert. 12.1a: Current Student (Summer) Cert. 12.6d: Language Subjects and Units Earned, Cert. 12.15: Lost Diploma
Cert. 12.1b: Current Student, units earned With GPA, Alumnus Cert. 12.16: No Objection
Cert. 12.1c: Current Student, GSIS Cert. 12.6e: Liberal Arts Subjects and Units Earned (pls. indicate name of requesting school
Cert. 12.1d: Current Student w/o GPA With GPA, Alumnus & address) _________________________
Cert. 12.1e: Former Student, units earned Cert. 12.6f: Language/Liberal Arts, Social Science ___________________________________
Cert. 12.2: Current Student w/ GPA Subjects and Units Earned w/ GPA, Alumnus ___________________________________
Cert. 12.3a: Former Student w/ GPA Cert. 12.6g: English Subjects and Units Earned with Cert. 12.18: Acceptance Notice
Cert. 12.3b: Former Student w/o GPA GPA, Alumnus Cert. 12.19: Affirmation on Diploma Reprinting
Cert. 12.4a: English as a Medium of Cert. 12.6h: English Subjects and Units Earned with Cert. 12.20: Diploma Correction
Instruction, student GPA, Student Cert. 12.21: Practice Teaching Units Earned
Cert. 12.4b: English as a Medium of Cert. 12.6i: Field Study (FS) Subjects and Units Earned with GPA, Alumnus
Instruction, Alumnus (Undergraduate) with GPA, Student Cert. 12.22: Practice Teaching Units Earned
Cert. 12.4c: English as a Medium of Instruction, Cert. 12.6j: Field Study (FS) Units Earned with with GPA, CPRT
Alumnus (Graduate & Undergraduate) GPA, Alumnus Cert. 12.23: Academic Honors with Ranking
Cert. 12.4f: English as a Medium of Instruction, Cert. 12.7: Current Student with Subjects Taken Cert. 12.25: Units earned (particular subject),
Alumnus (Undergraduate) Foreign Affairs Cert. 12.8a: Graduating with GPA Alumnus
Cert. 12.5a: English Units Earned, Student Cert. 12.8b: Graduating without GPA Cert. 12.26:Bonafide Student of MSU-IIT with ID
Cert. 12.5b: Education Units Earned, Former Student Cert. 12.9a: CAR Pending BOR Res. Cert. 12.27: Certification Graduate with Tadman
Cert. 12.5c: Education Units Earned, Current Student Cert. 12.9b: CAR w/o Thesis/Dissertation Cert. 12.28: Certification Legal Education
Board with Notary Public
Cert. 12.5d: Education Subjects and Units Earned Cert. 12.10: Graduation w/o GPA
Form 12.29: Certification Foreign Affairs, Consular
with GPA, Current Student Cert. 12.11: Graduation with GPA Section, Alumnus (Undergraduate)
Cert. 12.5e: Education Subjects and Units Earned Cert. 12.11A: Graduation with GPA Permit to Cross-Enroll
with GPA, Former Student & Equivalent Grade
Cert. 12.5f: Education Subjects and Units Earned Cert. 12.12: Academic Honors
with GPA, Alumnus
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.: Student Name: Student Alumnus
Contact No.: e-mail address: .
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) Assessment of Fees (to be filled out by Staff):
Sex: Date of Birth: Religion: Certification 150
Place of Birth: COR Reprinting 120
Citizenship: Civil Status: Report of Grades 120
Spouse (If Married): Authentication (10/page@ ___pp)
Name of Father: Evaluation 150
Name of Mother (Maiden Name): Reprinting of Lost Diploma 150
Address of Parents: TOR (50/page @ ___pp)
Name of Authorized Person: Transfer Credential 150
Mailing & Handling (OIS 01) 250
Requested by: Rush Job 160

Total Assessment ---------------------------------- Php _____

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.