Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan STUDENT‘S CLEARANCE Student's No.: NAME: Address : (Pls print) Surname F.Name | M.Name Date Filed: OR# Date Admitted in BulSU : Have you requested for any of the item below Course/Major/Section in BulSU previously? Ifyes, please specify HS. where graduated Did you transfer to BulSU?___ indicate the school you came from No. of terms in BulSU : Sem/Sum Total No. of Units earned: ________ Birthday: Ifyes, please Last Term in BulSU CHECK THE REQUESTED ITEM(S) BELOW:_ 1 Honorable Dismissal __ 4 Certification 2 Transcript of Records 5 Others, please specify —3 Diploma ‘THE ABOVE STUDENT IS CLEARED OF ALL MONEY AND PROPERTY ACCOUNTABILITIES IN MY OFFICE — — — — —(Tobesianedby the responsible officials concerned) __ Faculty Adviser: Dean: Librarian : VP for Students Affairs: ___ In charge, Accounting APPROVED: LEILANI M, LIZARDO Dated filed: NAME Course/Yr/Section/Major Your will be released on (Requested credential) Issued by: *** IMPORTANT *** ‘An AUTHORIZATION LETTER, ID of STUDENT AND ID of REPRESENTATIVE must be presented if subject student is not available to receive the requested document on the scheduled date of release.