X
ANNEX A
CAV FORM 1 - REQUEST FORM - SCHOOL (RF)
Republic of the Philippines
Department of Education
Region XIII
Division of Surigao del Sur
Control No.:_________________
Date of Application;___________
Date of Release:_____________
School Name:____________________________
School ID:____________________________
REQUEST FORM FOR ACADEMIC SCHOOL RECORDS
NAME OF LEARNER ;________________________________________________________
DATE & PLACE OF BIRTH :____________________________________________________
SCHOOL YEAR LAST ATTENDED /GRADUATED :_________________________________
PRESENT ADDRESS:________________________________________________________
ANNEXB
CAV FORM 2 - SCHOOL REFERRAL TO DIVISION OFFICE
Republic of the Philippines
Department of Education
Region_________________
Division_____________
School Name_________
1st Indorsement
Date
Respectfully forwarded to the Schools Division Superintendent, Division of
___________________________, requesting for assistance in securing a certified true copy of
School Form 18 (now School Form 5) for reconstruction of Form 137 in relation to the herein
attached request of Name of Learner, who claims to be a graduate of / student in
Name of School during the School Year__________. The said record, despite diligent search, is
not available in this Office.
For the preferential appropriate action of the Schools Division Superintendent.
Signature Over Printed Name
(School Head/Principal)
Attached: as stated.
ANNEXC
CAV FORM 3 - INDORSEMENT FOR CORRECTION OF ENTRIES IN THE ACADEMIC SCHOOL
RECORDS
Republic of the Philippines
Department of Education
Region________________
Division____________
School Name________
1st Indorsement
Date
Respectfully forwarded to the Regional Director, DepEd Regional Office_________,
_________(address)___________L (Attention: Attorney IV, Legal Unit) requesting for assistance in the
Correction of Entries in the Academic School Records of Name of Learner, a graduate of / student in
Name of School during the School Year________________________________________.
For ready reference and perusal, attached are the following documents / records:
1. Certificate of Live Birth (issued by Philippine Statistics Authority);
2. Affidavit of Discrepancy;
3. Affidavit of two (2) Disinterested Persons;
4. Form-137; and
5. Diploma
For the preferential appropriate action of the Regional Director.
Signature Over Printed Name (School
Head/Principal)
Attached: as stated.
ANNEXD
CAV FORM 4 - CERTIFICATION OF ENROLMENT / COMPLETION I GRADUATION
Republic of the Philippines
Department of Education
Region_______________
Division ______________
School Name___________
CERTIFICATION OF ENROLMENT / COMPLETION I GRADUATION
TO WHOM IT MAY CONCERN:
This is to certify that, based on available records in this school, the following
information pertaining to Name of Learner with Learner Reference Number_____________appear:
() enrolled in Grade_______during the School Year________
() completed Grade_______during the School Year________
() satisfactorily graduated from Elementary / Secondary Course for the School Year as
prescribed by the Department of Education*.
This certification is issued on__________upon the request of Name of Learner in
connection with hisi her application for Certification, Authentication and Verification.
Signature Over Printed Name
(School Head/Principal)
*tf graduated from secondary course in private school, indicate Special Order Number
and date.
ANNEX E
CAV FORM 5 - SCHOOL TRANSMITTAL TO THE REGIONAL OFFICE
Republic of the Philippines
Department of Education
Region________________
Division____________
School Name________
1st Indorsement
Date
Respectfully forwarded to the Regional Director, DepEd Regional Office_________,
________(address)___________, the herein request of Name of Learner for Certification,
Authentication and Verification (CAV) of his / her Academic School Records.
For ready reference and perusal, attached are the following documents/records
marked (\) below properly enclosed in sealed envelope:
( ) Certification of Completion/Graduation
( ) Certification of English as Medium of Instruction
( ) Form -137
( ) Diploma
For the preferential appropriate action of the Regional Director.
Signature Over Printed Name
(School Head/Principal)
Attached: as stated.
ANNEXF
CAV FORM 6 - LIST OF APPROVED CAV REQUEST
Republic of the Philippines
Department of Education
Region________________
Division ____________
School Name,_______
CONTROL DATE OF DATE OF
NAME
NO. APPLICATION TRANSMITTAL
xxxx notiling follows xxxx
Prepared by:
Signature Over Printed Name (School Records Custodian/Registrar)
Submitted by:
Signature Over Printed Name
(School Head/Principal)
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ANNEX G
CAV FORM 7 - CERTIFICATION OF NON-AVAILABILITY OF ACADEMIC SCHOOL
RECORDS IN THE DIVISION OFFICE
Republic of the Philippines
Department of Education
Region________________
Division_______________
CERTIFICATION
TO WHOM IT MAY CONCERN:
This is to certify that after due verification, there is no available records on file in this
Office of the requested Academic School Records (ASR) of Name of Learner.
Issued this_______day of_________, 20___for whatever legal purpose it may
serve.
Signature Over Printed Name
(Division Certifying Officer)
ANNEX H
CAV FORM 8 - RETURN INDORSEMENT OF SCHOOLS DIVISION OFFICE TO THE
SCHOOL
Republic of the Philippines
Department of Education
Region________________
Division_____________
2nd Indorsement
Date
Respectfully returned to Name of School Principal, Name of School, address of
school, the attached School Form 18 (now School Form 5) in connection with the request
for Academic School Records (ASR) of Name of Learner, a graduate of / student in that
school.
For the preferential appropriate action of the School Principal.
Signature Over Printed Name
(Division Certifying Officer)
Attached: as stated.
ANNEX I
CAV FORM 9 - CERTIFICATION OF DISCREPANCY IIES
Republic of the Philippines
Department of Education
Region________________
Division_______________
CERTIFICATION
TO WHOM IT MAY CONCERN:
This is to certify that, based on the duly verified School Form 18 (now School Form
5) on file in this Office, copy attached, the discrepancy / ies marked (V) below has / have
been noted in the Academic School Records (ASR) of Name of Learner, that school:
() Name: _________________________________________________
() Date of Birth:___________________________________________
() Place of Birth:__________________________________________
() School Year of Attendance:_______________________________
Issued this day of , 20 for whatever legal purpose it may
serve.
Signature Over Printed Name
(Division Certifying Officer)
Attached: as stated.
ANNEX J
CAV FORM 10 - REQUEST FORM (RF) FOR ALS A&E AND PEPT RATINGS
Republic of the Philippines
Department of Education
Region
Division_______________
Control No. : ________________
Date of Application: ___________
Date of Release: ___________
REQUEST FORM FOR RESULTS OF RATING ON:
() Alternative Learning Systems Accreditation & Equivalency Test
() Philippine Educational Placement Test
NAME OF LEARNER:______________________________________________________
DATE OF BIRTH:_________________________________________________________
PLACE OF BIRTH:________________________________________________________
PRESENT ADDRESS: _____________________________________________________
CONTACT NO.: __________________________________________________________
DATE OF EXAMINATION:__________________________________________________
PLACE OF EXAMINATION: _________________________________,________________
PURPOSE: (Please check any of the following):
□ EMPLOYMENT ABROAD I | FIANCE VISA | | STUDENT VISA
SEAMAN’S BOOK/SRC | | TOURIST VISA | I DESCENDANT’S VISA
MIGRATION ABROAD | | REIMBURSEMENT OF EDUCATIONAL
ALLOWANCE/TUITION FEES OF CHILDREN OF
OFWs
| | SUCH OTHER PURPOSE AS MAYBE REQUIRED BY THE DFA
Signature Over Printed Name
(Applicant / Representative)
ANNEX J
CAV FORM 10 - REQUEST FORM (RF) FOR ALS A&E AND PEPT RATINGS
CAV FORM 11 - CERTIFICATION OF NON-AVAILABILITY OF RATING (A&E IPEPT)
Republic of the Philippines
Department of Education
Region________________
Division_______________
CERTIFICATION
TO WHOM IT MAY CONCERN:
This is to certify that after due verification, there is no available records on file in this
Office of the requested Results of Rating on () Alternative Learning Systems Accreditation
and Equivalency Test ( ) Philippine Educational Placement Test of Name of Learner.
Issued this_______day of_________, 20___for whatever legal purpose it may
serve.
Signature Over Printed Name
(Division Records Officer)
ANNEXL
CAV FORM 12 - CERTIFICATION OF RATING (A&E IPEPT)
Republic of the Philippines
Department of Education
Region________________
Division ___________
CERTIFICATION
TO WHOM IT MAY CONCERN:
This is to certify that, after due verification, the following information marked
(V) below pertaining to Name of Learner, appear in the records of this Office:
( ) he / she passed the Alternative Learning Systems Accreditation and Equivalency
(ALS A&E) Test for Elementary / Secondary Level administered on: and he / she
has the competencies comparable to that of a
Elementary / Secondary graduate in the formal school system and as such, is
eligible to enter secondary / tertiary education.
( ) he / she took the Year Philippine Educational Placement Test (PEPT) given at
______________________with Examinee Number______________which indicate
that he / she has met the basic academic requirements of Year Level in the
Elementary / Secondary Level: and he / she, therefore, is eligible for admission to
Year Level subject to the satisfaction of other school admission requirements.
Issued this__day of_________, 20___for whatever legal purpose it may serve.
Signature Over Printed Name
(Schools Division Superintendent)
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ANNEXM
CAV FORM 13 - DIVISION OFFICE TRANSMITTAL TO THE REGIONAL OFFICE
Republic of the Philippines
Department of Education
Region________________
Division____________
1st Indorsement
Date
Respectfully forwarded to the Regional Director, DepEd Regional Office_________,
________ (address)_____________, the herein request of Name of Learner for Certification,
Authentication and Verification (CAV) of Academic School Records.
For ready reference and perusal, attached are the following documents/records
marked (V) below property enclosed in sealed envelope:
() Certification of Results of Rating
OALSA&E
()PEPT
() Diploma
() Form 137
() Others:________________________________________________________________
For the preferential appropriate action of the Regional Director.
Signature Over Printed Name
(Schools Division Superintendent)
Attached: as stated.
ANNEX N
CAV FORM 14 - LIST OF APPROVED CAV REQUEST
Republic of the Philippines
Department of Education
Region________________
Division____________
School Name________
DATE OF DATE OF
CONTROL NO. NAME
APPLICATION TRANSMITTAL
xxx nothing follows xxx
Submitted by:
Signature Over Printed Name
(Schools Division Superintendent)
ANNEX O
CAVFORM15- CAV APPLICATION FORM
Republic of the Philippines
Department of Education
Region
Control No.: ___________________
Date of Application: _____________
CAV APPLICATION FORM
NAME OF LEARNER:______________________________________________________
DATE OF BIRTH:_________________________________________________________
PLACE OF BIRTH:________________________________________________________
PRESENT ADDRESS: _____________________________________________________
CONTACT NO.:___________________________________________________________
NAME OF SCHOOL;_______________________________________________________
ADDRESS OF SCHOOL:___________________________________________________
[ I EMPLOYMENT ABROAD
| | FIANCE VISA
PURPOSE: (Please check any of the following):
I ! STUDENT VISA
| j SEAMAN’S BOOK / SRC | | TOURIST VISA | | DESCENDANT’S VISA
I I MIGRATION ABROAD | | REIMBURSEMENT OF EDUCATIONAL
ALLOWANCE/ TUITION FEES OF
CHILDREN OF OFWs
{ | SUCH OTHER PURPOSE AS MAYBE REQUIRED BY THE DFA
Signature Over Printed Name
(Applicant / Representative)
(TO BE FILLED-UP BY THE REGIONAL OFFICE)
Requirements
1. Student Permanent Record (Form 137)
2. Diploma
3. Certificate of Completion / Graduation
4. Special Order
5. Certificate of Accreditation (for PAASCU
Accredited Schools)
6. Transmittal
7. ALS A&E/PEPT
a. Certification from BEA
ANNEX O
b. Rating
c. Certification from Division Office
8. Passport Size Picture (2 pcs.)*
9. Documentary Stamp * If the applicant is not the learner himself I herself
ANNEXP
CAV FORM 16 - CAV FORM
Republic of the Philippines ATTACH PASSPORT
Department of Education SIZE ID PICTURE
Region______________
CERTIFICATION, AUTHENTICATION AND VERIFICATION
DATE:___________
CAV No.: ________
Series of 20_______
TO WHOM IT MAY CONCERN:
This is to certify that, based on duly verified available records on file, the following
information pertaining to Name of Learner appear, to wit:
( ) he / she completed the academic requirements of the Department of Education
for graduation from the course_____________________________in the School
Year_________in Name of School, as evidenced by herein attached marked
(V) below:
() Student Permanent Record (Form 137)
() Diploma
() Certification of Special Order
( ) he / she completed the academic requirements of the Department of Education
for Grade_______________/ Year Level______of the Elementary / Secondary
course_________________in tine School Year___________in Name of School,
as evidenced by herein attached Student Permanent Record (Form 137).
( ) he / she passed the Alternative Learning Systems Accreditation and
Equivalency (ALS A & E) Test for Elementary / Secondary Level administered on
___________________________: and he / she has the competencies
comparable to that of a Elementary / Secondary graduate in the formal school
system and as such, is eligible to enter secondary / tertiary education as
evidenced by herein attached Certification of Rating and Diploma.
( ) he / she took the Year Philippine Educational Placement Test (PEPT) given at
_______________________with Examinee Number____________which indicate
that he / she has met the basic academic requirements of Year Level in the
Elementary / Secondary Level: and he / she, therefore, is eligible for admission to
Year Level subject to the satisfaction of other school admission requirements as
evidenced by herein attached Certificate of Rating.
This Office further certifies the veracity and authenticity of the attached records
herewith; and issued in connection with the application of Name of Applicant for
__________purposes.
Signature Over Printed Name
(Regional Director)
Not valid without official seal, with erasure or alteration
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