校        長         教    頭        事務長         教務課長            進路指導課長         学年主任        担   任         係
 
 
 
 
                                                   証     明        書        交    付        願
                                                                                                     令和          年        月      日
      川崎医科大学附属高等学校長殿
                                                                               第             学年          組
 
                                                                               平成・令和                 年   卒業¹     卒業²見込
                                                                               氏     名                                            印
                                                                               旧氏名         （                              ）
 
 
      下記のとおり証明書を交付してくださるようお願いします。
 
 
                                                                         記
 
                      在 学 証 明 書                           通        第             号    *       書類提出先
   該当を○印
 
 
 
 
                      卒 業 証 明 書                           通        第             号    *
                      成 績 証 明 書                           通
 
                      調        査    書                       通
 
                      単位修得証明書                           通
 
                           〒         
  送付先住所
  電 話 番 号
                           TEL（              ）                    
                            昭和
  生 年 月 日                                       年               月                      日
                            平成
                            平成
  卒 業 年 月                                       年               月
                            令和
 
 
  備             考   *
 
  申請者・代理人           □ 運転免許証           □    健康保険証            □     住民基本台帳カード                □   パスポート
  確 認 書 類              □ その他（                                                               ）
 
                在    学
   契
 
 
 
 
                卒    業
                成 績
                調査書
   印
 
 
 
 
                単    位
                修    得
 （注）太枠内の該当箇所を記入してください。＊欄の記入は不要です。