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Email: pic1@pic.edu.ph
PACIFIC TelNo: (632) 872-0773
TelFax: (632) 478-7710
INTERCONTINENTAL Mobile No: (+63) 917 570 5039

COLLEGE B-30 L-20 Silver cor. Marble Road

Pilar Village, Las Piñas City
Metro Manila
P H I L I P P I N E S 1750
TRANSNATIONAL EDUCATION PROVIDER

FORM E201

REQUEST FORM
No. of Amount

Request for: Copies (For use of

Accounting Office)
Name: Student No.: ___________________ [ ] 1. Diploma _____ ______________
[ ] 2. Transcript of Records _____ ______________
_____________________________________________________ [ ] 3. Honorable Dismissal
Last Name First Name M.I.
Maiden Name: _______________________________________ (Attach Copy of Clearance) _____ ______________
(Surname used upon entry at the University [for female students/graduates only]) [ ]4. Certificate of Complete
Birthday:___________________________________ [ Academic Requirement _____ ______________
Course: _____________________________________________ [ ] 5. Certification of Grades _____ ______________
Entry Year: From: ____________ To: _________________ [ ] 6. Certification of Graduation _____ ______________
Date of Graduation:_________________________________
(If applicable) [ ] 7. Certification of Units Earned _____ ______________
Previous School [ ] 8. CHED Certification (CAV CHED)
Endorsement Letter (for CAV) - Free
Course: _____________________________________________ CAV CHED PhP80.00 (Certification)
Entry Year: From: ____________ To: __________________ CAV PIC PhP150.00
Transportation Fee
Date of Graduation:__________________________ It is required to request for CERTIFICATE OF UNITS EARNED for
Endorsement letter. Please see Number 7 for CUE fee.

Purpose [ ] 8. Certification of Enrollment _____ ______________

[ ] 9. Certification on Medium of
A. Transcript of Records (TOR)
[ ] 1. Evaluation Instruction _____ ______________
[ ] 2. Employment/Promotion [ ] 10. Replacement of Registration
[ ] 3. For further studies (Specify the college/university) Card/ID (with Affidavit of Loss) _____ ______________
____________________________________________ [ ] 11. PROSPECTUS
[ ] 12. Certificate of Registration _____ ______________
B. Others: __________________________________________
[ ] 13. Others: ___________________ _____ ______________

Contact Details _________________ _____ ______________

Permanent Address: _____ ______________
TOTAL
___________________________________________________
___________________________________________________ Please fill-out after payment
Fax No: ________________ Direct Line: _______________
Cell Phone No: ___________________________ Official Receipt No.: _________________________________
Email Address (for notification purposes only): Date: _________________ Amount Paid: _______________
___________________________________________________

(For use of the Office of the Registrar)

Name of Receiving Registrar’
Applicant’s Signature:
Date Received: ____________________
Date of Release: ___________________ Date Filed: _______________________________

Requirements: ______________ Book/s & CD: ___________________

Application form [ ] Name and Signature Name and Signature
2x2 Picture [ ]
TOR [ ]

Grades: ____________________ Payment: _______________________

Name and Signature Accounting Name and Signature
First Term [ ] First Term [ ]
Second Term [ ] Second Term [ ]
Third Term [ ] Third Term [ ]
Fourth Term [ ] Fourth Term [ ]
Fifth Term [ ] Fifth Term [ ]
Sixth Term (PHD) [ ] Sixth Term (PHD) [ ]

TD/CE: ____________________ Check by : __________________________

Name and Signature Director
Comprehensive Exam________________
Pre Oral___________________________
Final Defense ______________________