太枠内を
                                     証 明 書 発 行 申 請 書（記入例）黒ボールペンにて
                                                                                       （申請者は太枠内を記入すること。）
                                                                                                           記入する                                     全
  東京都立                桜修館中等教育                 学校長 殿           申請年月日             令和〇 年             〇 月 〇 日
                                                                                                                                                        定
  下記により証明書の発行を申請します。                                       申請者氏名                            桜 修 太 郎
 
 使用目的                                                                                                           おうしゅう たろう              性別
                                                                                 （ ふりがな ）
 (記入例1)受験に必要 ※裏面調査書出願予定先報告欄を記入
 (記入例2)奨学金申請に必要                                                            氏           名             桜 修 太 郎                       男
 (記入例3)就職先に提出                                                      証
 (記入例4)留学¹に必要（英文希望）※下に氏名をローマ字で記入                            生 年 月 日            平成〇       年    〇 月        〇 日生
 などを記入する
           ※大学入試選抜等に調査書を発行する場合は，裏面の                 明
             「調査書出願予定先報告欄」も必ず記載すること。                       住        所 〒 〇△□ー〇△□□
 （英文証明書の場合）                                                       を
 氏 名（ローマ字）
                                            Oshu Taro                                東京都〇〇区△△ 〇丁目〇番〇号
 
  1. 卒業証明書・・・・・・・・・・・・・・・・         1（英文） 通        受 （連絡先電話番号）                  〇〇     〇〇〇〇  〇〇〇〇
  2. 修了証明書・・・・・・・・・・・・・・・・                       通    け    ※在校生             生徒証明書番号
  3. 成績証明書・・・・・・・・・・・・・・・・                       通                           在校生は学年組・担任氏名を記入
  4. 単位修得証明書・・・・・・・・・・・                  1          通    る    第         学年            組：担任氏名
  5. 調査書・・・・・・・・・・・・・・・・・・・・・                 通          ※卒業生等           最終学年担任氏名            △△ △△
                                                                            人 □東京都立大学附属高等学校
                           必要枚数を記入
  6. 在学証明書・・・・・・・・・・・・・・・・                       通
                     英文希望の場合は、
  7. 卒業見込証明書・・・・・・・・・・・                             通         □東京都立桜修館中等教育学校
                                                                                 昭和                        転学
  8. その他（                        枚数の横に（英文）と記入
                                           ）                通                  平成 2  年 3 月 卒業 ・                                年         組
                                                                                 令和                        退学
 
                                                   証明書申請受付簿兼発行決定簿
                                                           卒業・転学・退学した
                                                                                                卒業・転学・退学のいずれかに〇
 収受印                               保存期間            1学校名にチェック
                                                               年 分類記号                 D100000 文書の取扱い 企画室保存 引
                                                                                                転退学の場合は                 継
                                      宛      先                      申請者                    在学時の学年組を記入
                                                                                                  発信者名          校長       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、上記申請のあった                                  決 定              年      月         日
 
                                                          証明書の発行を許可する。                      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
                                  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
 
 
 
 
                                  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
 
 
 
 
      ※調査書出願予定先報告欄
                                          昭和
                                                                     卒業
                              9   期生    平成   2   年    3    月 見込 ・ 卒業 ・ 退学                  年         組
                                          令和
                            （ ふりがな ）                     おうしゅう たろう                              性別
                             氏          名                    桜 修 太 郎                                     男
 
 
            学校名                 学部名                 学科名                   日程            受験形態
 1          ○○大学              △△学部                ◇◇学科                  前期     一般・学校推薦型・総合型
 
 
 2          △△大学              ◇◇学部                □□学科                  後期     一般・学校推薦型・総合型
 
 
 3                                                                                           一般・学校推薦型・総合型
 
 
 4                                                                                           一般・学校推薦型・総合型
 
 
 5                                                                                           一般・学校推薦型・総合型
                            出願先情報を記入
 6                                                                                           一般・学校推薦型・総合型
 
 
 7                                                                                           一般・学校推薦型・総合型
 
 
 8                                                                                           一般・学校推薦型・総合型
 
 
 9                                                                                           一般・学校推薦型・総合型
 
 10                                                                                          一般・学校推薦型・総合型