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GSR Form No.

04 (Revised 2016)

Republic of the Philippines


POLYTECHNIC UNIVERSITY OF THE PHILIPPINES
Office of the Vice President for Academic Affairs

APPLICATION FOR RE-ADMISSION


(For returning students)

GRADUATE SCHOOL

Date: __________________
The Dean
Graduate School
Dear Sir/Madam:
I wish to apply for re-admission this
School Year 20___-20____.

First Semester, Second Semester, Summer term,

Kindly evaluate my previous academic records for my re-admission this SY 20 ____ - 20 ____.
Name:

___________________________________________________________ ________________
Family name
First Name
Middle Name
Student Number
Course/Program Enrolled in: ____________
Total Units Earned in PUP-GS: _____________
School Year admitted in PUP-GS: _____Semester, School Year _________ / Summer, SY___________
Last term/School Year attended: _____Semester, School Year _________ / Summer, SY ___________
Academic Status:

Completed academic requirements as of ____Sem., SY________/Summer______


Took and Passed the Comprehensive Examination on _____________________

Reason/s for Stopping: ________________________________________________________________


Reason/s for continuing my studies: ______________________________________________________

_________________________
Signature over printed name

Deans Action/Recommendation:
________________________________
________________________________
________________________________
________________________________

Attachments:

____ O.R.: re-admission fee


____ Program of studies
____ Certificate of Grades

==========================================================================

CLEARANCE
THE ABOVE STUDENT IS CLEARED OF ALL MONEY AND PROPERTY RESPONSIBILITIES IN MY OFFICE.
(TO BE SIGNED BY THE DULY AUTHORIZED REPRESENTATIVES OF THE RESPECTIVE OFFICES CONCERNED)

1. G.S. LIBRARY

__________________________

(Ground Floor, GS Bldg.)

Readmission fee: P ______________

__________________________

(3rd Floor, South Wing, Main Campus)

2. ACCOUNTING OFFICE ______________________


(Ground Floor, South Wing, Main Campus)

3. INTERNAL AUDIT
4. LEGAL OFFICE

__________________________

(3rd Floor, South Wing, Main Campus)

O.R. No.: _________________

Date Paid: ______________