Republic of the Philippines

Province of Masbate
MASBATE POLYTECHNIC AND DEVELOPMENT COLLEGE, INC.
Bachelor of Agricultural Technology
STUDENT’S CLEARANCE FORM
Year Level:
1st Year 2nd Year 3rd Year 4th Year

Name of the Student: ____________________________________________________

Last Name First Name Middle Name
Student Number: ________________________________ Reasons for Clearance
Contact Number: ________________________________ a. Enrolling
Email Address: ___________________________________ b. Graduating
Block/section: __________________________________ c. Transferring
Academic Year: _________________________________ d. Others
st
1 Sem 2nd Sem rd
3 Sem
Academic Year Last Attended: __________________________________
(for old student returnees)
No. Department Clearing Officer Signature Date Remarks

1 Laboratory/Shop

Mr. Dandi Lloyd C.

 Swine Production
Laurio
Ms. Shainabe R.
 Poultry Production
Riva
Mr. Dandi Lloyd C.
 Crop Production
Laurio
Tool Room Mr. Winjie A.
2
Rapsing
Library Ms. Clarissa M.
3
Cambosa
NSTP(CWTS/ROTC) Mr. Winjie A.
4
Rapsing
Cashier Ms. Jessalyn E.
5
Huelva

6 Student Development Services

Ms. Clarissa M.
 CSC
Cambosa
Eleazar L.
 Guidance Office
Candidato, EdD
Ms. Robelyn F.
 Scholarship
Verano
7 Class Adviser

Canteen Ms. Clarissa M.

8
Cambosa
Program Head Mrs. Rosalinda R.
9
Verano
Registrar Ms. Robelyn F.
10
Verano

(In accomplishing this form please be guided by the instruction at the back)
INSTRUCTIONS:
1. Secure Student’s Clearance Form at the Registrar’s Office.

2. Laboratory/Shop in-charge clears the student of accountabilities in terms of

utilization of equipment/tools. The laboratory/shop pertained to here are the
following: Swine Production, Poultry Production, and Crop Production.

3. Librarian clears the student of accountabilities in terms of book/s or any other

library’s information material/s.

4. Cashier clears the student of any financial obligation.

5. Office of Student Development Services clears the student on matters that

concern the different units namely Discipline, Guidance and Scholarship, as well
as the different student organizations.

6. Canteen personnel clears the student of any financial obligation.

7. Class Adviser clears the student of accountabilities concerning classroom

maintenance; the class adviser coordinates with the different subject instructors if
there are other concerns that need to be settled

8. Program Head checks whether the student has subjected himself to evaluation
in the previous semester (enrolment purposes) to ensure that all units required for
the program have been met; for graduating, whether the academic requirements
have been completed.

9. Registrar checks the form for complete clearance by other relevant departments.

10. This clearance shall be presented to the enrolling officer during enrolment or
when claiming for transfer credential, Transcript of Records (TOR), diploma and
other
certification.

Note: The student needs first to write in full the names of their respective class adviser and
program head before requesting their signatures.