過年度生用                                    調査書発行申請用紙（学校控）                                          整理番号〔                 〕
 
                回生（      年3月卒）                     3年時            組                   担任                             先生
 氏名                                               現住所                                                              Tel（   ）         
                                                         入試
 No.       大学名          学部          学科       日程 区分 合否   大学・学部・学科コード 受験番号 出願期間                         入試日 発表日
 
 例       神戸大学          工           機械         前           1 3 3 0 4 6 0 2 1 0 5963            1/242/2                            2/25   3/8
  1                                                                                                                                        /      /
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 12                                                                                                                                        /      /
                                   進学・就職・浪人・その他              （進学先名称を学部・学科まで記入）
      【最終進路先】
                                 ↑（最終進路に○をつける）
       【入試区分】
         A: AO入試 自:自己推薦¹ ス:スポーツ 一:一芸      指:指定校    公:公募推薦²     3:3月入試（二次・二期） ※一般入試は空欄のまま
       【合否】
             1: 進学   2: 合格  3: 補欠   4: 不合格   5:未受験    6: その他
 
       【記入上の注意】              ◎日程の欄には、国公立大入試の日程「前」「後」「中」を記入する。
                                   大学・学部・学科コードは進研・駿台11月マークのコードを使用（わからない場合は空白で可能です）
 
 
 
                                                    き          り          と          り
                                                調査書発行用紙（本人控）
                                                      キ リ ト リ
 
 
                                            志望大学・学部・学科名
 
                         大学                        学部                                    学科                               合否
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 ※合否結果が判明した時点で、調査書を発行していただいた先生
 に連絡してください。  〔学校の電話番号：0794242726〕
                                                      ［進路指導部 メール kakohigashi-hs-si@hyogo-c.ed.jp ］