BATAAN PENINSULA STATE UNIVERSITY BPSU-ROF-022

OFFICE OF THE UNIVERSITY REGISTRAR revised 07/01/2017

City of Balanga 2100 Bataan APPLICATION FOR
PHILIPPINES SPECIAL OR
TUTORIAL CLASS
CAMPUS CHOOSE
Date of Application

Name 1st Sem 2nd Sem Summer/Midyear

Student No. Sex: Male  Female Academic Year
Program Curriculum Year
Major Contact No.

REQUEST OF STUDENT
I am graduating this semester/term but was not able to take the following course/s because of the reason/s indicated
below:

Course
Course Title Reason/s
Code

May I be allowed to have special/tutorial class/es in the said course/s?

I fully understand and agree that displacement /tutorial fee shall be collected over and above the cost per unit of the
course/s requested.

Student's Full Name

APPROVAL
This is to recommend that this request for special/tutorial class/es be approved with the schedule of classes below as
accepted by the Faculty:

Course Signature over printed

Course Title Schedule
Code name of Faculty

This further certifies that the student is graduating this term, that the course/s is/are not being offered during this
semester/term, and cross-enrollment is not possible.

Recommending Approval: Recommending Approval:

Signature over Printed Name of the Program Signature over Printed Name of the Dean
Head/Evaluator
Date/Time: Date/Time:

Approved by:

Campus Registrar

Date/Time:

IMPORTANT: This form is not a registration form. Accomplish in three (3) copies. If this application is approved, it is the
student's responsibility to ensure that this form is returned to the Campus Registrar's Office and he/she completes the
necessary changing of enrollment. No application for tutorial class shall be processed after two (2) days from the start of the
term.