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: registrar@g.msuiit.edu.ph
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.
