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Copy for the University Registrar

UNIVERSITY OF THE PHILIPPINES


OPEN UNIVERSITY
College, Laguna

UNIVERSITY CLEARANCE FORM FOR STUDENTS


Fill out this form completely and submit to your LC Coordinator together with the proof of payment of graduation fee
(for graduating students)
Important Note: Always retain one copy which you will present to the Office of the Registrar each time you
transact business requiring clearance (e.g. application for transcript, claim of diploma, etc.)

(PRINT IN BLOCK LETTERS)


NAME: __________________________________________________________________________________
(Family)
(First)
(Middle)
STUDENT NO.:___________________________
LEARNING CENTER:________________________
PROGRAM: _____________________________

MAJOR: ________________________________

First Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Last Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Reason for
clearance:_____________________________________________________________________________

_____________________________
Learning Center Coordinator
______________
Date

___________________________________
In-Charge, Library
________________
Date

______________________________
Faculty Dean
______________
Date

Graduation fee paid under O.R. No. _________________dated___________________


___________________________________________
Vice Chancellor Finance and Administration

__________________
Date

___________________________________________
University Registrar

____________________
Date

Deposit fee of PhP 100.00


( ) For refund
( ) For donation to UPOU Alumni Foundation (UPOU AFI)
Note: If I do not request a refund of the deposit fee a semester after the approval of the clearance from the
university, I am authorizing the UPOU to transfer the funds to UPOU AFI
________________________________
Signature of Student

_________________
Date

Copy for the Faculty Dean

UNIVERSITY OF THE PHILIPPINES


OPEN UNIVERSITY
College, Laguna

UNIVERSITY CLEARANCE FORM FOR STUDENTS


Fill out this form completely and submit to your LC Coordinator together with the proof of payment of graduation fee
(for graduating students)
Important Note: Always retain one copy which you will present to the Office of the Registrar each time you
transact business requiring clearance (e.g. application for transcript, claim of diploma, etc.)

(PRINT IN BLOCK LETTERS)


NAME: __________________________________________________________________________________
(Family)
(First)
(Middle)
STUDENT NO.:___________________________
LEARNING CENTER:________________________
PROGRAM: _____________________________

MAJOR: ________________________________

First Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Last Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Reason for
clearance:_____________________________________________________________________________

_____________________________
Learning Center Coordinator
______________
Date

___________________________________
In-Charge, Library
________________
Date

______________________________
Faculty Dean
______________
Date

Graduation fee paid under O.R. No. _________________dated___________________


___________________________________________
Vice Chancellor Finance and Administration

__________________
Date

___________________________________________
University Registrar

____________________
Date

Deposit fee of PhP 100.00


( ) For refund
( ) For donation to UPOU Alumni Foundation (UPOU AFI)
Note: If I do not request a refund of the deposit fee a semester after the approval of the clearance from the
university, I am authorizing the UPOU to transfer the funds to UPOU AFI
________________________________
Signature of Student

_________________
Date

Copy for the Cashier

UNIVERSITY OF THE PHILIPPINES


OPEN UNIVERSITY
College, Laguna

UNIVERSITY CLEARANCE FORM FOR STUDENTS


Fill out this form completely and submit to your LC Coordinator together with the proof of payment of graduation fee
(for graduating students)
Important Note: Always retain one copy which you will present to the Office of the Registrar each time you
transact business requiring clearance (e.g. application for transcript, claim of diploma, etc.)

(PRINT IN BLOCK LETTERS)


NAME: __________________________________________________________________________________
(Family)
(First)
(Middle)
STUDENT NO.:___________________________
LEARNING CENTER:________________________
PROGRAM: _____________________________

MAJOR: ________________________________

First Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Last Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Reason for
clearance:_____________________________________________________________________________

_____________________________
Learning Center Coordinator
______________
Date

___________________________________
In-Charge, Library
________________
Date

______________________________
Faculty Dean
______________
Date

Graduation fee paid under O.R. No. _________________dated___________________


___________________________________________
Vice Chancellor Finance and Administration

__________________
Date

___________________________________________
University Registrar

____________________
Date

Deposit fee of PhP 100.00


( ) For refund
( ) For donation to UPOU Alumni Foundation (UPOU AFI)
Note: If I do not request a refund of the deposit fee a semester after the approval of the clearance from the
university, I am authorizing the UPOU to transfer the funds to UPOU AFI
________________________________
Signature of Student

_________________
Date

Copy for the Student

UNIVERSITY OF THE PHILIPPINES


OPEN UNIVERSITY
College, Laguna

UNIVERSITY CLEARANCE FORM FOR STUDENTS


Fill out this form completely and submit to your LC Coordinator together with the proof of payment of graduation fee
(for graduating students)
Important Note: Always retain one copy which you will present to the Office of the Registrar each time you
transact business requiring clearance (e.g. application for transcript, claim of diploma, etc.)

(PRINT IN BLOCK LETTERS)


NAME: __________________________________________________________________________________
(Family)
(First)
(Middle)
STUDENT NO.:___________________________
LEARNING CENTER:________________________
PROGRAM: _____________________________

MAJOR: ________________________________

First Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Last Enrollment:

[ ] 1st [ ] 2nd [ ] 3rd Semester/Trimester/Summer, _____________- ____________

Reason for
clearance:_____________________________________________________________________________

_____________________________
Learning Center Coordinator
______________
Date

___________________________________
In-Charge, Library
________________
Date

______________________________
Faculty Dean
______________
Date

Graduation fee paid under O.R. No. _________________dated___________________


___________________________________________
Vice Chancellor Finance and Administration

__________________
Date

___________________________________________
University Registrar

____________________
Date

Deposit fee of PhP 100.00


( ) For refund
( ) For donation to UPOU Alumni Foundation (UPOU AFI)
Note: If I do not request a refund of the deposit fee a semester after the approval of the clearance from the
university, I am authorizing the UPOU to transfer the funds to UPOU AFI
________________________________
Signature of Student

_________________
Date