Republic of the Philippines
WESTERN MINDANAO STATE UNIVERSITY
OFFICE OF THE UNIVERSITY REGISTRAR 1904
Zamboanga City
Zamboanga City
Normal Road, Baliwasan, Zamboanga City 7000 [Link]
Philippines email registrar@[Link]
Tel No. (062) 991-1771 Fax No. 993-0695 WMSU-REG-FR-001.03
Effective Date – 15 May 2018
REQUEST FORM
NAME: _________________________________________ Civil Status: ____ Gender: _____
(PLEASE PRINT LEGIBLY) (SURNAME) (FIRSTNAME) (MI)
COURSE: ____________________________________________________________________________
(LATEST) (PREVIOUS) (YEAR GRADUATED)
Where earned-Pls. Check Box Main Campus External Studies Unit
Date of Attendance _________________________________________________________________________
(Pls. indicate semester / school year (Latest / Previous))
NATURE OF REQUEST: (Please check)
Transcript of Records Certification
Certificate of Eligibility for Transfer (CEFT) Completion of Grades
Authentication Diploma
CAV Others (Pls. specify) ______
__________________
I. Requirements: Student’s Signature
1. Clearance Date: _____________
2. Birth Certificate (PSA Authenticated)
3. Marriage Contract (for married women)
4. Form 137 A
5. CEFT (For transferee Students)
6. Transcript of Records (Photocopy for reference)
7. CERTIFICATION from the dean that Thesis Bound Books (Graduate & Undergraduate courses) or
Dissertation Bound Books (Doctoral Courses) are submitted to the College Dean concerned.
8. Notarized authorization letter & Valid I.D. for representative to claim
requested document/s in students’ behalf.
9. Picture 2X2 (1 pc.) with plain (white) Background
10. Official Receipt #______________ dated: ___________ Amount: ________
11. CAV-photocopies of TOR, Diploma, (RLE for BSN)
II. Payments:
CEFT (P150/Page) P____________
TOR (P150/Page) ____________
Certification (P50/Cert) ____________
Completion of Grades (P50) ____________
Diploma (P300 Original Copy; P200 Replacement) ____________
Authentication (P50/A Maximum of 4 Sets) ____________
CAV (P80/CAV) ____________
TOTAL P____________
ERIC H. ALFARO, MPA, LLB
University Registrar
To Concerned Student/Authorized Representative:
Please present this request form when you claim your records on
___________________ /___________________
Date and Time
_______________________
Data Evaluator/Date
RFW -
DATE:
