記入例
                                              証明書交付申請書兼交付台帳
 
                                                                        ※申請年月日： 令和              年      月      日
 
                          卒業          成績           修了          単位修得       調査書                収入証紙
   証明書の種類
                         400円          400円         400円            400円        500円                 ちょう付欄
 
                                         種類ごと必要部数を
     請求枚数               1            記入してください
 
 
 
                                              塩尻市高出○○
                                                                                証紙は同封してください
       住所
                            連絡がとれる番号
                                                          TEL     △△ー××××
 
       氏名                                   ○○              □□                                      ※
 
                     昭和
     生年月日        平成             12 年           4     月       10     日生
                     令和
 
    卒業（退学）         昭和                                                         卒業
                         平成            31               年
        年               令和                                                         退学
 
  卒業（退学）時の       全日
                                                                     学年            1       組
                                       総合学    科
   学科・学年・組        定時                                        担任          ○○                  本人確認書類
 
                     1   大学等の入学のため
                     2   就職¹のため
     申請理由        3   資格取得のため                                                                        ※
                     4   その他（具体的に）
 
 
 
     上記の者に証明書を交付してよいでしょうか。
 
 
      決裁権者
                            回                                                               議                事務担当者
    事務長専決
 
 
        ※                                                ※                                                        ※
 
 
 
       番号                 証明年月日                           件数                     金額                    備考
 
 
        ※                       ※                             ※                           ※   円                ※
 
 
 ※印欄は記入等しないでください