Form No.
UR-01-201904
FOR ENROLLMENT SERVICES HUB USE ONLY
CLEARANCE RECEIVED BY ID VERIFIED BY
REQUEST FOR DOCUMENTS
PLEASE PRINT
AY/Term Processing Regular Express
Date Requested CLAIMING/DELIVERY INSTRUCTIONS
Date Due
PERSONAL INFORMATION COURIER. Please send the documents via courier to
Last Name the address indicated here. It is understood that the
delivery period is over and above the processing
First Name
period.
Middle Name
Gender Male Female PICK-UP. The documents will be claimed by the
Birthday (mm/dd/yyyy) owner who will present one (1) valid ID and the Official
Receipt upon claiming.
Did you have a No
PROXY. A proxy/representative will be sent to claim
change or the documents. Upon claiming, he/she will have an
correction of Yes, my original name was authorization letter from the owner, his/her one (1)
name at DLSU? _________________________ valid ID and one (1) valid ID of the owner, and the
Official Receipt.
ACADEMIC INFORMATION CONDITIONS AND REMINDERS
ID Number 1. Under existing laws, only the owner of the records is allowed to
request for documents in connection with his/her school records
Program/Degree and claim the requested documents.
Campus Taft Laguna BGC 2. The University reserves the right to withhold, deny or cancel any
request for document due to pending accountabilities.
3. To verify the identity of the requesting/claiming party, one (1)
valid Identification Card shall be required for presentation upon
request and one (1) upon claiming of the documents.
Yes, I graduated on 4. Requests and claiming of documents by representative/proxy
Did you graduate ______________________ should be covered an accomplished Proxy Request of Records
Date (Form No. UR-06-201308) or an authorization letter. The
from DLSU?
No, my last enrollment was proxy/representative must present his/her one (1) valid ID and
on Term ___, AY ___ - ___ one (1) of the owner.
5. Production of requested documents requires considerable effort
and is subject to cut-off. Hence, cancellation, substitution,
refunds due to change of mind and the like will not be entertained.
6. Documents not claimed after sixty (60) days will be destroyed.
CONTACT INFORMATION
Cell. No. CONFORME
Email Address I have read and understood all the conditions and
Address reminders in connection with this request and agree to
(with Zip Code) comply with them.
s __ _
Signature over Printed Name Date
ALL RIGHTS RESERVED. Parts of this material may be reproduced provided (1) the material is not altered; (2) the use is non-
commercial; (3) De La Salle University is acknowledged as source; and (4) DLSU is notified through [email protected].
PLEASE SEE BACK FOR DOCUMENT TYPE TO BE REQUESTED
Last Name First Name Middle Initial
PLEASE DO NOT FILL PRICE COLUMN – TO BE ASSESSED BY THE ENROLLMENT SERVICES HUB
DOCUMENT TYPE QUANTITY PRICE
Transcript of
For Board Exam/PRC Purposes
Records
For Employment Purposes
For Evaluation Purposes
For BAR Exam Purposes (DLSU JD graduate only)
Certification Academic Units Completion
(For GS Comprehensive Exam/Thesis Enrollment)
Candidacy for Graduation (from week 10 of final term)
Course Description (up to 5 courses per certificate)
Cumulative GPA
Dean’s Honors List for Term ___ AY ____ - ____
English as the Medium of Instruction
Enrollment Term ___ AY ____ - ____
Graduation/With Honors
Units Earned
Courses Taken, Term ___ AY ____-____ (max. of 3 terms)
Certified True
Copy
Diploma (Bring original)
Transcript of Records (prior to DLSU)
Form 137 (High School Transcript)
Form 138 (High School Report Card)
Breakdown (Misc. Fees) for Term ___ AY ___-___
Duplicate Diploma (Bring Notarized Affidavit of Loss)
CHED/DFA Certification, Authentication, Verification (CAV)
Others:
______________________________________________
SPECIAL INSTRUCTIONS
Subtotal
TOTAL 0.00
Assessed
By
