GSR Form No.

08 (Revised 2016)

Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES APPLICATION FOR
Office of the Vice President for Academic Affairs
GRADUATE SCHOOL
GRADUATION

Date: __________________
The Graduate School Registrar
This University

Madame:

I expect to finish my course this ______ Semester of the School Year 20____- 20____ with the
degree of Doctor/Master in/of ___________________________________________.

Please print legibly.

LAST NAME FIRST NAME MIDDLE NAME Civil Status

PERMANENT ADDRESS Tel. No.

Mobile phone no.
PROVINCIAL ADDRESS Tel. No.

OFFICE AND ADDRESS Tel. No.

E-mail
SCHOOLS ATTENDED:
Elementary Year Graduated:
High School Year Graduated:
College Year Graduated:
Post Baccalaureate Year Graduated:
Post Graduate Year Graduated:
SCHOOL YEAR ADMITTED IN PUP-GS: LAST TERM ATTENDED IN PUP-GS:
________Semester/Summer, SY ______-______ ________Semester/Summer, SY ______-______
DATE OF COMPREHENSIVE EXAMINATION:
DATE OF THESIS/DISSERTATION DEFENSE:
Title of Thesis/Dissertation:

PENALTY SUBJECTS TAKEN, if any

CODE SUBJECT TITLE SEMESTER SCHOOL YEAR PROFESSOR

CURRENTLY ENROLLED SUBJECTS

CODE SUBJECT TITLE DAY TIME PROFESSOR

NOTE: Please attach Student records/ grades (from your SIS account) & Official Receipt (application fee)

I hereby certify that I am currently enrolled in the abovementioned subjects for the _______ Semester,
School Year 20___ - 20___ and that I have complied with all the course requirements of the program.
Very truly yours,
__________________________
Applicant’s signature
Student Number ______________

CLEARANCE
The above-named applicant is cleared of all money and property responsibilities in my office.
(To be signed by the authorized representative of each office)

1. GS Library ______________________ 2. Accounting Office _____________________