St.

Clare College
Caloocan, NCR
Philippines

INSTITUTIONAL STUDENT CLEARANCE FORM

Senior High School

Name: _________________________________________
LRN No: _______________________________________
Program: _______________________________________
Strand (if applicable): ______________________________
First Enrollment: Grade 11__________ 20__ - 20__
Last Enrollment: Grade 12__________ 20__ - 20__

Reason for Clearance: GRADUATION

Clearance Signatories:

_____________________ _____________________
Dr. Catherine S. Pagulayan Dr. Lita S. Sagun
Office of the Student Affairs and Services Counselor, Center for Guidance Services

______________________ _____________________
Mr. Jayvee S. Dizon Ms. Justine Jaycee Ili
Accounting Records Management

______________________ Class Adviser: _________________

Ms. Maria Rebecca P. Palad
Principal

___________
Date

Graduation fee paid under O.R No. (disregard if not graduating) ____________________

_______________________________
Student Signature over Printed Name