様式7                                                                                                                                           第                       号
 
                                       在学生・卒業生等                                                  割 印
                                        （該 当 す る 項 目を ○ で 囲 む）                              校     長          事務長                                  発議年月日
 
 
        証明書発行申請書（発行台帳）
                                                                                                                                                   年         月         日
                 岩手県立黒沢尻北高等学校長¹ 様
                                         下記の証明書を発行してください。
         （どなたの証明ですか？）
 
 
 
 
                                          氏            名                                                                  生年
                                                                                                        性別                                              年            月         日生
                                                                                                                            月日
                                          旧            姓
                                                                〒
                                          現     住     所
                                                                                                                     電話番号                      （         ）
 
                                       卒業年次及び             卒業年度                   年度           （卒業年月日                        年         月         日）
                                       在学時の状況             学科                     普通科               年    組                        年         月         日修了
 
                        ※                                      氏     名 （自筆のこと）                                                 本人との関係（続柄）
                          申                請     者            現            住           所     〒
                                    (学校に来た人)
                                                                 電       話        番      号                                 （             ）
                                                                □    在学証明書                        通               □      修了証明書                             通（            ）
                                                                □    卒業証明書                        通（          ） □      成績証明書                             通（            ）
                                     証明書種類                 □    卒業見込証明書                    通               □      単位修得証明書                         通
                                                                □    調査書                            通               □      その他（                      ）       通
                                                                          ＊   卒業 ・ 成 績 証 明書 の 英 文 を希 望 す る 場 合は （    ） に「 英 文」 と 記 載 す るこ と 。
 
                                     申 請 理 由
                                                                     □受験          □資格取得           □就職            □その他（                                        ）
                                    （何に使いますか？）
 
                                                                                                                                                                   受    付        印
                                     提     出     先
               （どこに提出しますか？）
 
 
                                                                英文の場合
                                     そ     の     他
                                                                パスポート上の表記
 注1      申 請 者 を 確認 す る た め身 分 を 証 明 する 書 類 （ 運転 免 許 証 、健 康 保 険 証 等） の 提 示 を求 め る こ と があ り ま す 。
   2         本 人 以 外 の 申請 者 の 場 合は 、 委 任 状 が必 要 で す 。
   3           郵 送 で 申 請 する 場 合 は 、送 付 先 を 記 入し 切 手 を 貼っ た 返 信 用封 筒 を 同 封 して く だ さ い。
   4           本 人 が 申 請 する 場 合 は 、※ 印 欄 は 記 入す る 必 要 があ り ま せ ん。
   5           本 人 が 閲 覧 する た め の 証明 書 の 発 行 はし ま せ ん 。
   6           県立高等学校の卒業生等については、証明手数料が必要ですので、下欄の納付書に岩手県収入証紙を貼付のうえ、申請
        し てく だ さ い 。
 
 
                                                                         県立学校諸証明事務証明手数料納付書
         岩手 県収入証紙 貼付欄
        ※1 400 円×必 要 通数 分
                    2 消印 し な い こ と。
                    3 枚数 が 多 く 貼 りき れ な
                                い 場合 は 裏 面 添 付の こ と 。
 
 
                                                                                                                                                           年           月         日
         岩手県立黒沢尻北高等学校長² 様
             次のとおり納付します。      一金                                                                             円也
               ただし、県立学校諸証明事務証明手数料として