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Page 1: Dependent Form

Republic of the Philippines

MINDANAO STATE UNIVERSITYMarawi City

HUMAN RESOURCES DEVELOPMENT OFFICE

C E R T I F I C A T I O NTO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that per records in this office, Mr./Ms. _________________ __________________________________ of the ______________________________________ this University is an employee of the said office/unit on _________________________ status.

This is to certify further that the following is/are his/her registered dependent As of _______June________ , 2013 to wit:

NAME/S RELATIONSHIP DEGREE/ COURSE SOUGHT

1. 2. 3.

This certification is issued upon request of Mr./Ms. ___________________________to avail of tuition privileges granted under BOR Res. Nos. 808 and 833 as implemented by Special Order No. 73, series of 1973

Issued this ____ th day of _____ __ 201_ at MSU, Marawi Philippines

__________________ Acting Director

Verified by: __________________________