Microsoft Office Suite

Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

Office of the Vice President for Academic Affairs

Senior High School Department

1

REQUEST FORM

(Date)

Due to the present situation, RELEASE IS THRU EMAIL The original copies may be claimed when conditionnormalizes. Step 1 - Secure a copy of the List of Requirements showing the Document Requested. A clear scan copy or photo of this will be submitted with this Request Form.

Step 2 – Fill up items I, II, III

I. Personal Information

Student Information

LRN: 136********* STRAND, YEAR & SECTION: STEM 12-3 NAME: GANUHAY, ALTHEA DENISE CUESCANO

(Last Name) (First Name) (Middle Name)

DATE GRADUATED: (If Applicable)2020 Contact No. (Landline, if any) N/A Contact No. (Cellphone) 094******** E. Mail Address: adikrw@r.postjobfree.com II. Document Requested – Check from the list below the document(s) you are requesting and the no. ofcopies.

(Pls. check)

No. of

copies (Pls. check)

No. of

copies

Certificate of Ranking Informative Copy of Grades

Certificate of Good Moral Character 1 Cancellation of Enrollment (Retrieval Fee)

Certificate of Grades 1 Certificate of English Medium of Instruction Honorable Dismissal (Attach copy of Clearance) Certified True Copy of: (Pls. specify) F-138 (Grade 11 Card) E-Documentary Stamp 2

Certificate of Completion / Graduation Replacement of Registration Card / F -138 Certificate of Enrollment Second Copy of F-137

Others: (Pls. specify)

III. Purpose - Write the reason for requesting the document(s) For online admission to other universities.

ALTHEA DENISE C. GANUHAY

(Signature over Printed Name)

Step 3 – Payment of Fees (See the amount of fee in the table below and follow the payment procedure attached with this document) Requested Document Fee Requested Document Fee

All Documents including Certificates, others P 150.00 Second Copy of F-137 P 100.00 Cancellation of Enrollment (Retrieval Fee) 100.00 E-Documentary Stamp 30.00 each Note: The E-Documentary Stamp is necessary for Certificates. One Certificate is to One E-Documentary Stamp If you comply correctly with the Payment Procedure, you will receive the OFFICIAL RECEIPT issued by PUP Collections Office. Step 4 – Email this form (page 1) with the List of Requirements (see step 1) and OFFICIAL RECEIPT of payment issued by the PUP Collections Office to adikrw@r.postjobfree.com

SUBMISSION OF INCOMPLETE ACCOMPLISHED FORM & DOCUMENTS MAY AFFECT THE PROMPT RELEASE OF YOUR REQUEST.

Step 5 – Acknowledgment of your Email

Upon receipt of your request, the SHS-Registrar will acknowledge it and inform you of the estimated release date. Should you have queries, please contact the SHS-Registrar’s Office at 5335-1787 local 341. Thank you and Stay safe always.

June 24,2020

Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

Office of the Vice President for Academic Affairs

Senior High School Department

2

PAYMENT PROCEDURE OF FEES

1.1 Cash Deposit

a. Students who are candidates for graduation may make payment at any LBP branch. b. Before paying, fill-out the CASH DEPOSIT Slip using the following details. Example:

Account Name: PUP TRUST RECEIPTS

Clearing Account Number: 068*-****-**

c. Upon payment, the student shall send a copy of the Bank’s Validated Deposit Slip together with their Complete Name, Program (Senior High School), Student ID Number, Fee/Fees paid for Ex. Diploma P200, Certification P150, others and LBP Branch where the payment was made/ deposited and email it to adikrw@r.postjobfree.com . Please be advised that NO EMAIL, NO OFFICIAL RECEIPT. 1.2 Or Pay Via Fund Transfer

a. students may proceed with the payment via Fund Transfer using the following details: Account Number: 068*-****-**

Account Name: PUP Trust Receipts

b. after the successful fund transfer, send an email to adikrw@r.postjobfree.com of the following information/ details:

a. Transaction Reference Number

b. Complete Name of Student

c. Program (Senior High School)

d. Student ID Number

e. Fee/Fees paid for Ex. Diploma P200, Certification P150 Please be advised, NO EMAIL, NO OFFICIAL RECEIPT.

Example:

Contact this candidate