BU Form 101

(Pls. prepare in 4 copies)

Republic of the Philippines

Bicol University
Legazpi City

REQUEST FOR HONORABLE DISMISSAL

_________________

The University Registrar

Bicol University
Legazpi City

Dear Madam:

May I apply for an honourable dismissal from Bicol University in favour of

_________________________________ I have earned ___ units in _____________________________
(name of college/University where to transfer) (present course)
but I prefer to shift to __________________________ at the above-named this first/second semester,
20__-20__.

As of date, I am cleared of all money and property accountabilities and that I have never been involved in
any misconduct or subjected to any disciplinary action during my stay in Bicol University.

This move is with my parent’s/guardian’s knowledge and consent as borne out by his/her signature
below. I have also paid the amount of _________________ with official receipt number _____________
dated ____________ as payment for certificate of Honorable Dismissal, good moral character and
Official Transcript of Records.

Thank you.

Very truly yours,

__________________________
(Signature Over Printed Name)
__________________________
(Course Year)

CONFORME:

__________________________________
(Signature Over Printed Name of Parent/Guardian)

Certified by:

____________________________ / / Records is with the College

Registrar / / Records is with the URO

Recommending Approval:

__________________________
Dean

APPROVED:

____________________________
University Registrar