GSR Form No.

04 (Revised 2017)

Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES APPLICATION FOR RE-
RE-ADMISSION
Office of the Vice President for Academic Affairs (For returning students)
GRADUATE SCHOOL

Date: __________________

Dear Sir/Madam:

I wish to apply for re-admission this
First Semester,
Second Semester,
Summer term,
School Year 20___-20____.

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: ______________________________________________________

Registrar’s Evaluation/Recommendation: _____________________________

___________________________________ Student’s signature over printed name
___________________________________
___________________________________ Program Chair’s Action/Approval:
___________________________________ ________________________________
___________________________________ ________________________________
________________________________
Attachments: ____ O.R.: readmission fee (P200.00) ________________________________
____ Program of studies ________________________________
____ Certificate of Grades
____ Pre-registration form
==========================================================================

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 __________________________ 3. INTERNAL AUDIT __________________________

(Ground Floor, GS Bldg.) (3rd Floor, South Wing, Main Campus)
2. ACCOUNTING OFFICE ______________________ 4. LEGAL OFFICE __________________________
(Ground Floor, South Wing, Main Campus) (3rd Floor, South Wing, Main Campus)

Readmission fee: P ______________ O.R. No.: _________________ Date Paid: ______________