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Application For Academic Record

This document is an application form for students and alumni of the University of the East Ramon Magsaysay Memorial Medical Center to request academic records. It requests information such as the applicant's name, program, dates of enrollment and graduation. It lists the types of records that can be requested such as transcripts, certificates, and diplomas. Fees for copies and certifications are outlined. Signatures are required from various school offices to confirm clearance before the dean can approve the request. Upon approval, records will be released within 14 days for most items or 30 days for original diplomas.

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238 views1 page

Application For Academic Record

This document is an application form for students and alumni of the University of the East Ramon Magsaysay Memorial Medical Center to request academic records. It requests information such as the applicant's name, program, dates of enrollment and graduation. It lists the types of records that can be requested such as transcripts, certificates, and diplomas. Fees for copies and certifications are outlined. Signatures are required from various school offices to confirm clearance before the dean can approve the request. Upon approval, records will be released within 14 days for most items or 30 days for original diplomas.

Uploaded by

pasambalyrradjohndar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

64 Aurora Boulevard, Barangay Doña Imelda, Quezon City 1113 Philippines


: +632 715 0861-77 local 261 * +632 713 3315 *: [email protected]*: https://www.uerm.edu.ph

APPLICATION FOR ACADEMIC RECORD/S


STUDENT INFORMATION
DEGREE PROGRAM DATE OF GRADUATION
LAST NAME GIVEN NAME MIDDLE NAME
PERMANENT ADDRESS STUDENT NO.
E-MAIL ADDRESS LANDLINE PHONE NO. MOBILE NO.

PERIOD ENROLLED IN SY: ___________________________________ CURRENTLY Yes


FROM SY: ___________________________________ TO
THE MEDICAL CENTER TERM: 1st 2nd 3rd Summer TERM: 1st 2nd 3rd Summer ENROLLED? No

REQUEST FOR ACADEMIC RECORD/S


NO. OF NO. OF
AMOUNT AMOUNT
COPIES COPIES
CERTIFICATION
OFFICIAL TRANSCRIPT OF RECORDS ₱ GRADUATION ₱
MEDIUM OF INSTRUCTION
CERTIFICATE OF TRANSFER CREDENTIAL ENROLLMENT / ATTENDANCE
NON-ISSUANCE OF SPECIAL ORDER NUMBER
ORIGINAL DIPLOMA (ISSUED ONLY ONCE) GRADES
GENERAL WEIGHTED AVERAGE
CERTIFIED TRUE COPY COURSE / SUBJECT DESCRIPTION
TRANSCRIPT OF RECORDS
DIPLOMA CERTIFICATION, AUTHENTICATION AND VERIFICATION
DEPARTMENT OF FOREIGN AFFAIRS (DFA)
COMMISSION ON HIGHER EDUCATION (CHEd)
MAILING FEE
DOCUMENTARY STAMP/S
OTHERS, PLEASE SPECIFY

THE ABOVE DOCUMENT/S IS/ARE REQUIRED FOR MY:

SCHOLARSHIP TRANSFER TO OTHER SCHOOL EMPLOYMENT REFERENCE


RE-ADMISSION BOARD EXAMINATION FURTHER STUDIES OTHERS, SPECIFY ______________________________

GENERAL CLEARANCE
(Note: Previous graduates and currently-enrolled students should secure clearance from Registrar and Accounting Offices only.)

THE ABOVE NAMED STUDENT IS CLEARED OF ALL MONEY AND PROPERTY RESPONSIBILITIES IN MY OFFICE.

REGISTRAR ACCOUNTING GUIDANCE AND COUNSELLING MEDICAL CENTER LIBRARY BUDGET AND TREASURY
(2/F, Admin. Bldg.) (2/F, Admin. Bldg.) (G/F, Admin. Bldg.) (3/F, JMC Bldg.) (2/F, Admin. Bldg.)

DEAN’S RECOMMENDATION(Attach copy of latest statement of account APPROVED DEAN’S SIGNATURE DATE SIGNED
from Accounting Department, and clearance from various departments in the Medical
Center.) DISAPPROVED

I authorize the Center to control and instruct its authorized personnel to process all information I provided, including collecting, recording, organizing, storing, updating, modifying, retrieving,
consolidating, sharing, or using the information and/or documents provided in any other way necessary to pursue its legitimate interests in relation to my academic records request. I understand that
the Center may keep my information for historical and statistical purposes.

APPLICANT’S SIGNATURE OVER PRINTED NAME OR NO. / DATE RECEIVED BY / DATE RELEASED BY / DATE

AMOUNT PAID PROCESSED BY / DATE CLAIMED BY / DATE


UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.
64 Aurora Boulevard, Barangay Doña Imelda, Quezon City 1113 Philippines
: +632 715 0861-77 local 261 * +632 713 3315 *: [email protected]*: https://www.uerm.edu.ph

CLAIM STUB
DATE FILED RELEASE DATE
LAST NAME GIVEN NAME MIDDLE NAME
REQUEST FOR

NOTE:
1. PLEASE PRESENT THIS CLAIM STUB UPON CLAIMING YOUR DOCUMENTS TOGETHER WITH THE ORIGINAL AND PHOTOCOPY OF ANY TWO (2) VALID
GOVERNMENT-ISSUED IDs (e.g., DIGITIZED SSS ID, DRIVER’S LICENSE, GSIS E-CARD, PRC ID, IBP ID, UNIFIED MULTI-PURPOSE ID, VOTER’S ID, AND
SENIOR CITIZEN’S ID). OTHER ACCEPTABLE IDs INCLUDE UERM STUDENT ID, UERM ALUMNI ID AND CURRENT EMPLOYEE ID.
2. FOR REPRESENTATIVES, PROVIDE A VALID ID (SEE LIST ABOVE), LETTER OF AUTHORIZATION, AND A NOTARIZED SPECIAL POWER OF ATTORNEY IN
ADDITION TO THE IDENTIFICATION REQUIREMENTS ENUMERATED IN ITEM 1 ABOVE.
3. DOCUMENT/S REQUESTED (e.g., OFFICIAL TRANSCRIPT OF RECORDS, CERTIFICATIONS, ETC.) WILL BE ISSUED AFTER FOURTEEN (14) WORKING DAYS FROM
RECEIPT OF THIS APPLICATION TOGETHER WITH THE PROOF OF PAYMENT; ORIGINAL DIPLOMA WILL BE ISSUED AFTER ONE (1) MONTH FROM RECEIPT
OF THIS APPLICATION TOGETHER WITH THE PROOF OF PAYMENT.

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