証 明 書 発 行 申 請 書
                                                                                          （申請者は太枠内を記入すること。）
                                                                                                                                                            全
  東京都立                小石川中等教育                 学校長¹ 殿              申請年月日                  令和        年         月          日
                                                                                                                                                            定
  下記により証明書の発行を申請します。                                          申請者氏名
 
 使用目的
                                                                                    （ ふりがな ）                                                     性別
 
                                                                               証        氏            名
                                                                                                                  昭和
                                                                               明        生 年 月 日                         年           月           日生
                                                                                                                  平成
                                                                               を    住          所 〒
  1. 卒業証明書・・・・・・・・・・・・・・・・                          通
  2. 修了証明書・・・・・・・・・・・・・・・・                          通    受
  3. 成績証明書・・・・・・・・・・・・・・・・                          通          （連絡先電話番号）                                        
                                                                               け
  4. 単位修得証明書・・・・・・・・・・・                                通          ※在校生              生徒証明書番号
  5. 調査書・・・・・・・・・・・・・・・・・・・・・                    通    る                学部
  6. 在学証明書・・・・・・・・・・・・・・・・                          通          第          学年            組：担任氏名
                                                                               人
  7. 卒業見込証明書・・・・・・・・・・・                                通          ※卒業生等            最終学年担任氏名
                                                                                          昭和
  8. その他（                                      ）                    通               平成        年         月 卒業 ・ 退学                       組
                                                                                          令和
 
 
 
 
                                                   証明書申請受付簿兼発行決定簿
 収受印                               保存期間             1        年 分類記号                J500020        文書の取扱い                              引
                                                                                                                                                        継
                                      宛      先                                                           発信者名                校長²                 ぎ
 
                                      件      名          証明書等の発行について                            施     行         年        月        日
 
                                        本件について、                                                      決 定             年        月        日
 
                                                                                許可する。                  起 案             年        月        日
                                       決 定 権 者             審   議    者        起    案     者        文書取扱主任           公 印 照 合
 
 
 
 
 文書記号
                                                卒修成単調在卒                                                          卒修成単調在卒
   割       印           番           号                                            割    印          番         号
                                                業了績位査学見                                                          業了績位査学見