Office of the University Registrar

REQUEST FOR ACADEMIC RECORDS

NAME__________________________________________________________________________ Contact No. _________________

(SURNAME) (FIRST NAME) (MIDDLE NAME)

Please PRINT your name based on your birth certificate; If married, print name used during last enrolment.

Name of LATEST Program enrolled / completed at XU: ____________________________________________

Year Graduated: ____________

Purpose of Request - Please check ✔ below:

___board ___bar ___reference ___employment ___visa

DOCUMENTS: (please check ✔) Qty

___ Diploma 1
___ Authenticated copy of diploma ___

___ Transfer Credential/Honorable Dismissal (For those who will transfer to another school) 1
___ Transcript of Records (TOR) ___

___ Authenticated copy of TOR ___

___board ___bar ___reference ___employment ___visa

___ Authenticated copy of HS Report Card (F 138) ___

___ Authenticated copy of HS TOR (F 137-A) ___

___ Course Description (Please specify the subjects) ___

CERTIFICATES: (please check ✔)

___ Graduation ___

___ Letter of No Objection ___

___ Special Order ___

___ English as Medium of Instruction ___

___ Enrollment ___

___ CAV _____ Local ______ Abroad (Apostille) ___

___ GWA / QPI (for students enrolled after 2013) ___

___ Others: Please Specify:_____________________________________________ ___

MAILING REQUEST (please check ✔)

___ For Pick-up

___ For Courier delivery

Name of recipient: ____________________________________________

Address of recipient: ___________________________________________

Signature of Student:__________________________ Date: _______________

Payment Received by: __________________________ Date:__________________

Finance Office