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
 
                                                                                                           ○○年 卒業¹ 卒業²見込
 
 
 
 
                                                                                                                                      川崎
                                                                                平成・令和
                                                                                氏       名           川 崎        太 郎                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   *
                                                                                                       ・○○大学○○学部
                      成 績 証 明 書                            通                                       ○○学科
                ○    調        査     書                 1    通
 
                      単位修得証明書                            通
 
                           〒        ○○○○○○○
  送付先住所
                                     岡山県倉敷市○○○○
  電 話 番 号                                                                                        必ず連絡がつく番号を
                           TEL（       ○○○      ）○○○          ○○○○
                            昭和
                                                                                                     記入してください。
  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。