編        入               学        願          書
                                                                                                       令和        年    月       日
  広島市立基町高等学校長¹ 様
 
 
                                                                             志願者
 
                                                                             保護者
 
 
           次のとおり、全日制・普通科( 普通 ・ 創造表現コース )第                            学年へ編入学を志願します。
           なお、入学者選抜願は別途提出します。
              フ        リ        ガ        ナ
 
                   名                  前                                                       年            月         日 生
 志
                                                   〒              -
              現             住        所
                                                                                                         TEL(                          )
 
 願                                                                    立                            高等学校
              学             校         名
                                                                       制                            科 第         学年入学予定
                                                   〒              -
            学 校 所 在 地
 者                                                                                                      TEL(                              )
 
            編 入 学 理 由
 
                   名                  前
 保
                                                   〒
 護                                                自      宅                                            TEL(                              )
              連             絡        先
 者
                                                   勤務先等                                              TEL(                              )
  編        入      学        後        の         〒
  新                住                  所                                                               TEL(                              )
                        学                            校                名                   入 学 ・ 卒 業 ・ そ の 他
 志                                                               中学校第3学年       令和        年          月        日 卒業
 願
 者                                          立                 高等学校第1学年       令和        年          月        日 入学
 学
 歴
 
 
      ※     受         付        印              ※受付(受検)番号               注意 1. ※印の欄には記入しない。
                                                                                      2. 必要な文字を○で囲む。