様式第7号                                                                                                                                          第                    号
 
                                          在学生・卒業¹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
                     岩手県立前沢高等学校長                             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²年次及び            卒業³年度                     年度          （卒業⁴年月日                       年         月         日）
                                       在学時の状況            学科                                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⁵証明書                         通（         ） □ 成績証明書                                 通（            ）
                                     証明書種類                □     卒業⁶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 人及 び 本人 （ 県立 学校に 在 学 する 者 に限 る 。） の 保護者 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
         岩手県立前沢高等学校長 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