ABCDEFGHIJKLMNOPQRSTUVWXYZ
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CONTROL NO.: ______________________
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REPUBLIC OF THE PHILIPPINES
APPLICATION FOR
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POLYTECHNIC UNIVERSITY OF THE PHILIPPINES
LATE REPORTING OF GRADE
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OFFICE OF THE UNIVERSITY REGISTRAR
(Please attach certified photocopy of class record and Official Receipt)
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STUDENT RECORDS SERVICES
COMPLETION OF "INCOMPLETE GRADES"
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STA. MESA, MANILA
(Please attach photocopy of Official Receipt)
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CORRECTION OF ENTRY
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(Please attach certified photocopy of class record & Affidavit of Change of Grade)
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Others
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DATE: ____________________
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The Dean
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College of: ___________________________________________________
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I hereby request that
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Student Number: ___________________________ Name: ___________________________________________________________
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(Example: 2010-000001-MN-0)
(Last Name)
(First Name)
(Middle Name)
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Course: __________________________________
Year & Section: ________________________________________
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Subject Code: ___________________________________
Subject Title: ________________________________________
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School Year: ___________________________________
Term:
First Semester
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School Session:
Day
Second Semester
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NightSummer
Campus: __________________
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which was reported as:
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_________________________________________________________________________________________________
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_________________________________________________________________________________________________
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due to the following reason/s:
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_________________________________________________________________________________________________
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_________________________________________________________________________________________________
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be credited as one:
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who has "NO GRADE" in the Grade Sheets to a final grade of ______________________ ______________ units.
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who has completed all the requirements with a final grade of ______________________ ______________ units.
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GRADE:
First Grading : _______________
Second Grading: ____________
Final Grade : _______________
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whose name in the Grade Sheet be corrected
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From: _____________________________________________________________________________________
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(Last Name)
(First Name)
(Middle Name)
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To: _____________________________________________________________________________________
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(Last Name)
(First Name)
(Middle Name)
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Others, specify:
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___________________________________________________________________________________________
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___________________________________________________________________________________________
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Thank you.
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___________________________________________________
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PROFESSOR/INSTRUCTOR
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(Signature over Printed Name)
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APPROVED BY DEAN/CHAIRPERSON
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Name: _____________________________________________
Signature: __________________________
Date: _____________
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Received by Office of the Student Records, University Registrar
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Name: _____________________________________________
Signature: __________________________
Date: _____________
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