OFFICE OF THE UNIVERSITY REGISTRAR

University of the Philippines Dilinian

Quezon City
(TOR Trust Fund A Code No. 9774700)

CLAIM STUB NO.:

DUE DATE:

Note: To be checked only by O.U.R. Staff

Module FJj Manual
1 1St time To Apply University Clearance
Currently Enrolled (need copy of F5/paid on CRS)
I Updating
Note: Plersu PRINT your name Recopy
and address. Thank you. I Re-encoding Encoder & Checker-
2X2
or
grad
DiFOR MAILING:____
Required only for bar/board applicants RATES:
ure
11.111rerilrf 01 lfe(o,,lS (ontS Arkirtkmal rrrarrdalory IWO
f) P.1<10,I0: Ir.rriserrpt Guide) ihysuw/v,gr.
Applicallou, from aiuo.uri
IMPORTANT: For 1st time, Newly Graduate or Updating Application for Transcript of
m (irrClu otnraihnq/RerjIsIererI Mall on)
Records & other Documents must be accompanied by a University Clearance Cou/mOliii Cot/CAy
I1hp3O 00/copy
APPLICATION FOR: Course Description

No. of Copies Assessment/By: 1.11911sh Tutfl5Llluon of Dplonua & FRCfI - 13/

P1< uS 0.00/copy
Transcript of Records (TOR) Certified Irure c:ow ClOTS
II
PIth 00.00/0
Certificates/Documents: (Tertlueul liii: 1.0th? of COG & PC COW
11:1:1 5.0<1/copy
Cerhifreul 1 rile Co1uy 01 COurse Description
Graduation (COG) hhupls.0(l/l,.rqe
ehllfierJ 1 mc Copy 01 Dilhlunua trauslallun
Course Descriptions (CD) I'Iup?. 5. TO/c of up
DIlicial Cnn -small l'lupIO.00
P.E. Cert./Speclal Cert
-fliedrurn PhplS.00
-trifle Plgu20,00
No Objection Letter 'lauliug leesc
English translation of Diploma Itetun 1la,riIa l'lrplsO.00 (IOu (if lOg)
Luzou Php165.00/Vsayrs/1.11u(lauun- 1/5.00
(Plo. attach photocopy of diploma) (I.Ia, of I ky & uruy vary on localiou)
Abroad(US & Canada)
Nigh School Card/F 137 (Courier) lhipl,S0O.O0
(CAV) Certification, Authentication
& Verification (niA for Red Ribbon) DATE
Certified True Copy: AMT PAID
Official Envelope: 0 R. NO

I IMalling Fee: 2G0/DF-IL/RM Small

OTHERS:_ Medium

TOTAL AMOUNT TO PAY [ ) Large

PURPOSE OF APPLICATION [P15. check):
Employment [ ) Local [ ] Abroad Bar Exam
Scholarship [ j Local [ I Abroad PRC Licensure Exam:
Enrollment [ I Local [ Abroad LAE School:
Transfer to other School PRE-MED School:
I COPY FOR:
F I Others -

NAME OF STUDENT --
(Please Print Legibly) LAST FIRST MIDDLE MAIOEN
(Based on bIrth certIficate; If married, encircle family name used during last enrolment in U.P.)

PERMANENT ADDRESS: -

STUDENT NO.: FATHER'S NAME:

____E LILJLJ MOTHER'S MAIDEN NAME:

DATE OF BIRTH (Student):
PLACE OF BIRTh (Student):
PLEASE CHECK:
To be picked up personally (unclaimed TORs/COGs within 6 months are shredded)
IJj To be mailed to the following address (es) - -
(If more than one, attach mailing list)
CONTACT NO. OF THE RECIPIENT:

COLLEGE(S)/UNIT(S)0 DEGREE/MAJOR INCLUSIVE DATES DATE OF GRADUATION

ATTENDED IN U.P.

U.P. CAMPUS(ES) WHERE YOU CROSS REGISTERED (If any) INCLUSIVE DATES

For students who transferred or obtained their first degree from another school, please Indicate all schools attended
Name & Location of Previous School Inclusive Dates Degree/Title Obtained

Signature of Student: Tel/Mobile No.: EMAIL:

If representative is filing the application for the student, please furnish the following information:
Name of Representative: -- SIgnature: Tel/MobIle No.:
Complete Address: - - EMAIL:

NOTES: 1) After paying the application fee, submit your application and O.R. to the TOR Counter. You will be issued a CLAIM STUB
[together with the OR.], to be presented in claiming your transcript.
2) In compliance with R.A. No. 10173 (DATA PRIVACY ACT OF 2012), representative must submit a signed authorization letter with
photocopy of valid ID. of the student, presentation of valid I.D. of the representative and claim stub upon claiming the reguested
documents.

REV. jmbua 17762076