Request and Claim Slip Form

	Reference No. BatStateU-FO-REG-11	Effectivity Date: May 18, 2022	Revision No.:02
REQUEST AND CLAIM SLIP FORM

Name of Student :	Jessica De Chavez
Program:	Bachelor of Secondary Education	Year Graduated:	2025
Date of Filing:	June 19, 2025	Claim Date:
Official Receipt No.:		Contact Number:	09552918160

REQUESTED DOCUMENTS		NUMBER OF PIECES	UNIT COST (in Php)	AMOUNT
	Diploma		400.00
	Certificate of Transfer Credentials		100.00
	Form 137		100.00
	Certification		30.00
	Transcript of Records	2	50.00 per Page	100
	Authentication		20.00 per Page
	Second Copy of Registration Form		15.00
	Graduation Fee		1,000.00
	Others, please specify:
TOTAL AMOUNT TO BE PAID				100
Purpose/s		Board Examination / Employment

Requested by:

JESSICA DE CHAVEZ

Signature over Printed Name of Student

REF # :25-0619-37562

Checked by:

MERELYN JANE D. GAMAB

Signature over Printed Name of Registrar's Staff

Claim Slip
Name of Student :	Jessica De Chavez
Program:	Bachelor of Secondary Education	Year Graduated:	2025
Date of Filing:	June 19, 2025	Claim Date :
Requested Document/s:	Transcript of Records	Number of Copies :	2

REMINDERS:

In claiming a document through a representative,Authorization letter and valid IDs of Claimants are required.
Provide 2 pieces of documentary stamps for each copy of requested documents EXCEPT for authentication

Contact Numbers:

MERELYN JANE D. GAMAB

SIGNATURE OF REGISTRAR'S STAFF

REF # :25-0619-37562