Clearance Form for Extension Students

Form Reg. 13 A
BAHIR DAR UNIVERSITY
COLLEGE/FACULTY/INSTITUTE/SCHOOL OF ________________
CUSTOMERS RELATION & INFORMATION PRODUCTION CASE TEAM
EXTENSION STUDENT CLEARANCE SHEET
Purpose:
If you want to have a healthy relationship with the university, it is very important to the student to student 
to complete this clearance form properly & return it to the University registrar before you leave the 
university campus what ever the reason may be. Only with the proper termination below can official 
transcripts, letter of enrollment, student copy, or honorable dismissal be issued. Readmission to any unit of 
the university will be considered only if proper termination is certified  by the University registrar. 
Procedures:
o  Complete the firs part of this form.
o  Have terminal interviews with your academic Advisor.
o  Obtain the signatures designated below, showing that you have returned university 
property. 
o  Return this form to the Office of the Registrar on time.
o  This form becomes part of your permanent University file and record. 
Academic year _________ E.C    Semester ___________
Personal Data
_________________    _____________  _______________    _______
Name of the Student     Fathers Name    G/Fathers Name      Sex 
______________    __________ __I    II   III     IV   V    _______
Faculty/College/Institute/School  Program Year of study (circle it)    I.D. No
Reason  for clearing from the University (put ‘X’ in the appropriat e place)
End of academic year _________    Academic Dismissal _____________
Disciplinary case _______________    Withdrawing due to health/family problem _____
Graduation __________________    Forced withdrawal ___________________
If you have reason other than t hese, please specify it _______________________________
Date of application by the student ______/_____/_____/ E.C  _____________________
mm  dd  yy    Signature of the application
advisor’s reason to approve student’s clearance, if the reason is other than end of academic year ______
___________________________________________________________________________________
____________    _______/______/______E.C      ____________
Advisor’s name      mm     dd    yy         Signature 
Pleas obtain signatures from the following
Full name            Signature
1.  Library     ____________________      _____________
2.  Book Store   ____________________      _____________
3  Continuing Education Business Affairs   ____________________
4  Continuing Education Coordinator ___________________________       
Date of receiving the clearance, if necessary including the I.D card, by  Information and Documentation Case 
Worker  of CRIPCT.      ______/______/______ E.C
dd    mm yy
Extension