Republic of the Philippines

ROMBLON STATE UNIVERSITY

Odiongan, Romblon

APPLICATION FOR GRADUATION

2 x 2 Picture
The Dean (Surname, Given Name,M.I.)
Signature Over Printed Name
College/Institute of _____________________________________ Formal Attire
Romblon State University

ATTENTION: The University Registrar

Madam: 0
I have the honor to apply for graduation with, and conferment of the Degree of _____________________
_______________________________________. I have completed all the academic requirements as of
___________________________.

Very truly yours,

Student ID Number Printed name and signature

NOTE: FILL THE BLANKS IN TYPEWRITTEN OR PRINT

A. Personal Data:
Name:
(Family Name) ( Given Name) (Middle Name)
Age: Date of Birth: Place of Birth: Gender:
Home Address:
Parent or Guardian: _____________________________________
Address:

Name of school attended School Term

Primary: ___________________________________________________
Intermediate: ______________________________________________
Secondary: ________________________________________________
Collegiate: ________________________________________________
Degree applied for:
Major :

Credentials Submitted: ( please check)

Form 138 NSO Birth Certificate

Form 137A Marriage Certificate
ROSCAT Rating Honorable Dismissal
NROTC/CWTS Transcript of Records

In case a graduating student may have subjects with deficiencies at the time of evaluation please indicate and
fill in the following:

SUBJECTS WITH DEFICIENCIES

SUBJECT SUBJECT GRADES/ TERM & PROFESSOR/ INSTRUCTOR
CODE DESCRIPTION REMARKS ACADEMIC YEAR
 I am currently enrolled in the following subjects:

SUBJECT PRE- PROFESSOR/

SUBJECT DESCRIPTION UNITS GRADE
CODE REQUISITE INSTRUCTOR

Total

I fully understand that in case, any of my currently enrolled subjects will obtain an incomplete grade or "INC",
I should comply the requirements on or before _________. Otherwise, in case I was not able to comply with the
the lacking requirements at the given period for completion due to my negligence, the University has the
right not to allow me to join the Commencement Exercises pursuant to "Graduation Requirements" Chapter 10
of the Student Handbook and Section 1, Chapter 67 of the University Code.

Signature over Printed Name

Subjects loads and units taken by term:

TOTAL NO. OF UNITS

YEAR LEVEL TERM TAKEN ACADEMIC YEAR TAKEN
REQUIRED COMPLETED
First Semester
First Year Second Semester
Summer
Total
First Semester
Second Year Second Semester
Summer
Total
First Semester
Third Year Second Semester
Summer
Total
First Semester
Fourth Year Second Semester
Summer
Total
First Semester
Fifth Year Second Semester
Summer
Total
GRAND TOTAL

Date Accomplished: ________________________

Approved by:

Chairman/Adviser Dean University Registrar

Date: Date: Date:

Not valid without Alumni Fee OR No._____________

the university dry seal