PLM Form 1 (SY 2009)
PAMANTASAN NG LUNGSOD NG MAYNILA
(University of the City of Manila)
Intramuros, Manila
Office of the University Registrar
Amount
Applicant’s Information Request for:
No of
Copies (For use of
Accounting Office)
Student No.___________________ [ ] 1. Diploma _____ ______________
Name: _____________________________________________ [ ] 2. Transcript of Records _____ ______________
Last Name, First Name, M.I.
[ ] 3. Honorable Dismissal
Maiden Name:______________________________ (Attach Copy of Clearance) _____ ______________
[surname used upon entry at the University(for female students/graduates only)
Course: _____________ College:____________ [ ] 4. English Translation of Diploma _____ ______________
Entry Year from: ___________ to: ____________ [ ] 5. Certification of Grades _____ ______________
Date of Graduation: _______________________ [ ] 6. Certification of Graduation _____ ______________
[ ] 7. Certification of Units Earned _____ ______________
Purpose [ ] 8. Certification of Enrollment _____ ______________
[ ] 9. Certification of Medium
A. Transcript of Records (TOR) of Instruction _____ ______________
[ ] 1. Evaluation [ ] 10. Replacement of Registration
[ ] 2. Employment/Promotion Card/ID (with Affidavit of Loss) _____ ______________
[ ] 3. For Further Studies (Specify the College/ [ ] 11. DFA/CHED Authentication of
University)____________________________ Student’s Records _____ ______________
B. Others: _____________________________________
_____ ______________
[ ] 12. Others: _________________
Contact: _________________ _____ ______________
Permanent Address: TOTAL _____ ______________
Fax No: Please fill-out after payment
Contact No: _______________________
Cell Phone No: _____________________ Official Receipt Number: _____________________________
Email Address: (for notification purposes only) Date of Payment: ___________________________________
______________________________________________ Amount Paid: ______________________________________
(for use of the Office of the Registrar)
Name of Receiving Registrar’s Staff: __________________
Date Received: ___________________________________ Applicant’s Signature: ______________________
Date Released:_______________________________ Date Filed:_______________________________
Applicant’s Information Request for:
No. of
Copies
Student No.: _______________ [ ] 1. Diploma ________
Name: __________________________________________ [ ] 2. Transcript of Records ________
Maiden Name: ____________________________________ [ ] 3. Honorable Dismissal ________
Course: __________________ College:________________ (Attach Copy of Clearance)
Entry Year from: _______________ to: _________________ [ ] 4. English Translation of Diploma ________
Date of Graduation: _________________________________ [ ] 5. Certification of Grades ________
Please fill-out after payment [ ] 6. Certification of Graduation ________
[ ] 7. Certification of Units Earned ________
Official Receipt Number: _____________________________
[ ] 8. Certification of Enrollment ________
Date of Payment: __________________________________
[ ] 9. Certification of Medium of Instruction ________
Amount Paid: _____________________________________
[ ] 10. Replacement of Registration Card/ID
(for use only by the OUR staff) ( Present Affidavit of Loss) ________
[ ] 11. DFA/CHED Authentication of
Name of Receiving Registrar’s Staff: __________________ Student’s Records ________
Date Received: ___________________________________ [ ] 12. Others: _______________________ ________
Date Released: ______________________________ _______________________ ________
TOTAL
*Please see reminders at the back
Registrar’s Staff Signature: ________________
