(This sworn statement should be accomplished in four (4) copies and must be notarized by law.

Attached it with the original Transcript of Records required by the Department Order No. 12, 2
of 1962.)

I HEREBY CERTIFY that I have been actually enrolled in the graduate school or schools
listed on the accompanying transcript of record and that I have actually earned the units indicated
therein. As required by the Commission on Higher Education, has been furnished with authentic
copies of the Sworn Statement and its enclosures.

_____________________________
(Signature of the Teacher)

_____________________________
(Printed Name of the Teacher)

SUBSCRIBED AND SWORN to before me this _____________________ day of

__________________, 20_____ affiant exhibiting his/her Residence Certificate No
__________________ issued at _______________________________ on _________________.

_____________________________
NOTARY PUBLIC

DOC. No. ________

BOOK NO. _______
PAGE NO. ________
SERIES OF 20_____.