証 明 書 等 交 付 願
                                                                                    令和           年       月        日
 
      新潟第一中学・高等学校長                   様
                                      氏        名                                 印     （新氏名                       ）
                                                                                                        ※ある場合は記入
                                      生年月日（ S ・ H            ・     ・       ）
 
                                      現 住 所
 
                                      電話番号
 
       卒 業 証 明 書                                               単位修得証明書
       (卒業後永年)                                          通     （卒業後 20 年間）                                     通
 発
 行    成 績 証 明 書                                               調 査 書(大学受験以外)
       (卒業後 5 年間)                                       通     (卒業後 5 年間)                                        通
 希
 望
       発行不能証明書(成績)                                         発行不能証明書(調査書)
 書                                                          通                                                            通
       (卒業 6 年目の 4/1 から永年)                                 (卒業 6 年目の 4/1 から永年)
 類
       発行不能証明書(単位修得)
                                                             通                                                            通
       (卒業 21 年目の 4/1 から永年)
 
      ※手数料は、和文・英文ともすべて一通につき 400 円である。
 1   発行の理由
                           （例：就職活動・資格取得試験・奨学¹金申請などを記入）
 
 2   卒業又は修了年月日                   昭和 ・ 平成 ・ 令和          年        月(卒業時担任                 先生)
 
 
 3   書類提出先
                              （例：大学名・就職先・資格試験受験先などを記入）
 
      ※下欄には記入しないでください。
 
 
      交付年月日                令 和                年       月        日          卒業時担任印           手数料収納者
 
                                           証   第        001        号
       発行番号
                       （調査書）進 第                                  号
 
                                                                                     手
                                                                                     数
                                                                                     料
                                                                                     収
      契                                                                             納
                                                                                     欄                             円
 
 
      印                                                                             追
                                                                                     加
                                                                                     発
                                                                                     行
                                                                                     欄
                                                                                                                    円
 
                                                                                                          （R5.2.8）