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                      成瀬高等                 学校長¹ 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               F400000 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
                      証明書申請受付簿兼発行決定簿                 （裏）
 
 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