記入日                      年             月          日                                                   ( 過 年 度 卒 業 生 用 )
                               調        査    書        作     成      依           頼     書    (進路課提出用)
 平成・令和 (                             )年3月         卒業
 3年次クラス        (                    )組       ・    担当(                                               )先生
    氏
 
 
                                                                                                                                  男
    名
 
 
 
                                                                                                                                  女
                 平成 (                   ) 年 (                  ) 月 (                       ) 日 生
    連絡先 (TEL)                     (                            )                               
             ※ 該当する項目にレ点をして下さい。
    使
 
 
 
 
             □ 入学試験出願のため
    用
 
 
 
 
                          [ □推薦¹入試※1               □一般入試                  □社会人入試
    目
 
 
 
 
                            □その他      (                                                             ) ]
             □ 入学試験出願以外のため
    的
 
 
 
 
                          [ □奨学金          □特待生            □通信教育・放送大学
                           □就職             □その他（                                                 ）]
                 大
 
 
 
 
                                                                                          大     学      ※1 推         □要     □不要
                                                                                          学     部
                 学
 
 
 
 
                                                                                                                薦      必要な場合は用紙を添付して
 
                                                                                          学     科             書      下さい
    提
 
 
 
                 短
 
 
 
 
                                                                                          短     大
                                                                                                        連絡事項があれば記入して下さい。
                                                                                          学     科
                 大
    出
 
 
 
 
                                                                                      専攻・コース
            専       修                                                                   学     校
    先
 
 
 
 
            各       種                                                                   学     科
            学       校                                                               専攻・コース
                 その他
 
 
 
 
         提出先所在地（                                       ）都・道・府・県
 ※この依頼書は調査書1通につき1枚必要です。調査書の発行には4日程度（土日祝除く）かかります。
 （ 以下学校使用欄 ）
             ※ 1．合格                      2．追加合格                      →   （変更                                       ）
                          3．不合格                                                                         a．入学
                          4．調査書提出せず                  5．受験せず                                   b．入学せず
 
             確認手段                1．通知             2．本人より                    3．TEL                    確認者印
 
             確認日                      月               日
 
              調査書発行台帳（過年度卒業生用）
 校長       教頭              教頭        事務長                                     受付         作成                 発行番号
                                                                      進路 課
 
 
 
 
                                                                                                                          第              号
 
 
                                                                                                                          割印
                                                                      受付日              月      日
                                                                      引渡日              月      日
                                                                                                      以降