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                       井草高等                学校長 殿          申請年月日                            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                                                                                                                                        性別
                                                                                 （ ふりがな ）
 
                                                                           証        氏          名
 
                                                                           明        生 年 月 日                       年           月           日生
 
                                                                           を    住        所 〒
  1. 卒業証明書・・・・・・・・・・・・・・・・                      通
                                                                           受
  2. 修了証明書・・・・・・・・・・・・・・・・                      通
  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¹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
  8. その他（                                      ）                通                         年        月    卒業 ・ 退学                     組
 
 
                                                   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         D100000
 
                                             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        担    当   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
                                           委任状
 
 
 私は（代理人   住所）
 
 
     （代理人   氏名）
 
 
 を代理人と定め、下記の行為につき権限を委任します。
 
 
 
 
                                              記
 
 
 
 【委任事項】
   都立井草高等学校発行証明書の申請・受け取り
 
   ・証明書内訳   （該当項目にチェックを入れ、発行枚数¹を記入）
 
       □   卒業証明書                             通
       □   修了証明書                             通
       □   成績証明書                             通
       □   単位修得証明書                         通
       □   調査書                                 通
       □   在学証明書                             通
       □   卒業見込証明書                         通
       □   その他（               ）              通
 
 
 
                                                                 年   月   日
 
                                （委任者   住所）
 
 
 
 
                                （委任者   氏名    ※自署）                     印