S T U D E N T ‘S C L E A R A N C E
In accordance with the provisions of the Data Privacy Act of 2012 and its corresponding implementing rules and
regulations, we implement reasonable and appropriate security measures to ensure the security of the personal
information we gather. We will collect, process, and store your personal information for the purpose of processing
your document request.
I authorize and give my consent to the Office of the University Registrar for the purpose stated above.
_________ __________________________________________________
Student’s No.: _____________
NAME: ________________________________________ Address: ___________________________________
(PRINTED) Surname F. Name M. Name Date Filed: ______________O.R. No.: ___________
Date Admitted in BulSU: __________________________ have you requested for any of the item below
Course/Major/Section in BulSU: ____________________ previously? _______________ If yes, please specify
H.S. where graduated: ____________________________ ___________________________________________
Did you transfer to BulSU? _______If yes, please indicate Last Term in BulSU: _________________________
the school you came from: _______________________ Purpose of Request: _________________________
No. of terms in BulSU: Sem/Tri/Sum: _______________ Contact No.: ________________________________
Total No. of Units earned: ________________________ Email Address: _____________________________
Student’s Signature: ______________________________ Birthday: ___________________________________
CHECK THE REQUESTED ITEM (S) BELOW:
-------------------------------------------------------------------------------
______1. Honorable Dismissal ______4. Certification
______2. Transcript of Records ______5. Others, please specify
______3. Diploma ____________________________
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THE ABOVE STUDENT IS CLEARED OF ALL MONEY AND PROPERTY ACCOUNTABILITIES IN MY
OFFICE
(To be signed by the responsible officials concerned)
_____________________________________________________________
Faculty Adviser: ________________________________ Dean: ______________________________________
Librarian: _______________ Dean of Student Affairs ________________ In-charge, Accounting______________
APPROVED:
MA. MAGDALENA V. GATDULA, PCpE, DT
University Registrar
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(SLIP for the student)
TO: ________________________________________________________________________________________
NAME Course/Year/Section/Major
Your _____________________________________will be released on ____________________________
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***IMPORTANT***
An AUTHORIZATION LETTER, ID of the STUDENT, and ID of the REPRESENTATIVE must be
presented if the subject student is not available to receive the requested document/s on the scheduled date of release.
BulSU-OP-OUR-02F2
Revision: 1
