卒業生調査書交付願 ［2面・私立他］                                           卒業年度（           ）年度 旧クラス（        ）組 旧担任（              ）先生      名前（                                     ）
           ※太枠の中（受験大学・学部・学科、方式、受験種別、コード番号）を記入してください。
 
                    受験大学・学部・学科
                                                          方式                         受験種別                          コード番号
                                                                                                                                          出願開始日   出願〆切      受験日        合格発表日   調査書不要×
                                                                                                                                                                                                                    担任
                                                    （大学の呼称）               （該当するものに○印）            （河合塾コード表より）                                                                             
                                                                      指定校推薦¹ ・ 公募制推薦 ・ 総合（旧AO) ・                                        月    日
      1                                                                                                                                   月    日                    月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦² ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      2                                                                                                                                   月    日                    月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦³ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      3                                                                                                                                   月    日                    月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦⁴ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      4                                                                                                                                   月    日                    月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦⁵ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      5                                                                                                                                   月    日                    月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦⁶ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
 私   6                                                                                                                                   月    日                    月      日      月   日
 立                                                                       一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
 大                                                                   指定校推薦⁷ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
 学   7                                                                                                                                   月    日                    月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
 ・
 短                                                                   指定校推薦⁸ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      8                                                                                                                                   月    日                    月      日      月   日
 大                                                                       一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
 ・                                                                   指定校推薦⁹ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
 専   9                                                                                                                                    月    日                   月      日      月   日
 門                                                                       一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
 学                                                                   指定校推薦¹⁰ ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
 校   10                                                                                                                                   月    日                   月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦 ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      11                                                                                                                                   月    日                   月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦 ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      12                                                                                                                                   月    日                   月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦 ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      13                                                                                                                                   月    日                   月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦 ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      14                                                                                                                                   月    日                   月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                      指定校推薦 ・ 公募制推薦 ・ 総合（旧AO) ・                                         月    日
      15                                                                                                                                   月    日                   月      日      月   日
                                                                          一般 ・ 共テ型 ・ 一般共テ併用型                                             消印・必着
                                                                     ＊共通テスト併用型は一般入試として取り扱う
           ※   「卒業生調査書交付願」にご記入いただいた受験大学の必要枚数分しか発行できません。追加が必要な場合はその都度申請してください。
           ※   使用しなかった調査書は学校へ返却してください。なお、証明書発行手数料はお戻しできません。
           ※   同一大学で複数の学部を受験する場合、調査書の提出は1通でも学部はすべて記入してください。