ANNEX D

CAV FORM 4- CERTIFICATION OF ENROLLMENT/COMPLETION/GRADUATION

Republic of the Philippines

DEPARTMENT OF EUCATION
Caraga Region
Division: Siargao
School Name: Burgos National High School

CERTIFICATION OF ENROLLMENT/COMPLETION/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 ____N/A__________ appear:

( ) enrolled in Grade ________ during the School Year_________

( ) completed Grade ________ during School Year ___________
( ∕ ) Satisfactorily graduated from Elementary / Secondary Course for the School Year
2003-2004 as prescribed by the Department of Education.

This certification is Issued on _January 29, 2019 upon the request of LENIE D. ESCOBAL
in connection with his/her application for Certification, Authentication and Verification.

RANDY M. TOKONG, MAEd

Head Teacher II

 If graduated from secondary course in private school, indicate Special Order Number
and Date.
 ANNEX F
CAV FORM 6- LIST OF APPROVED CAV REQUEST

Republic of the Philippines

DEPARTMENT OF EDUCATION
Caraga Region
Division: Siargao
School Name: Burgos National High School

CERTIFICATION

Control Number Name Date of Application Date of Transmittal

2019-001 Lenie D. Escobal 01/29/2019

XXX nothing followsXXX

Prepared by:

MIRASOL O. NOGALIZA
(School Records Incharge/ADA’S II)

Submitted by:

RANDY M. TOKONG, MAEd

Head Teacher II
 ANNEX 5

CAV FORM 5- SCHOOL TRANSMITTAL TO THE REGIONAL OFFICES

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region: Caraga
Division: Siargao
School Name: Burgos National High School

1st Indorsement
Date: ________________
Respectfully forwarded to the Regional Director; DepEd Regional Office, Butuan
City, Agusan Del Norte, the herein request of LENIE D. ESCOBAL 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.

RANDY M. TOKONG, MAEd

Head Teacher II

Attached as stated.
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Caraga Administrative Region
Butuan City

APPLICATION FORM
CERTIFICATION, AUTHENTICATION AND VERIFICATION (CAV)
ELEMENTARY/SECONDARY

NAME OF STUDENT APPLICANT: LENIE DOMIṄOS ESCOBAL_____________________________________

COMPLETE DATE OF GRADUATION/LAST SCHOOL YEAR ATTENDED: __APRIL 2, 2004________________
YEAR LEVEL COMPLETED (FOE non-graduate): _______________________________________________
NAME OF SCHOOL: BURGOS NATIONAL HIGH SCHOOL________________________________________
ADRESS OF SCHOOL: __BURGOS NATIONAL HIGH SCHOOL____________________________________
Special Order No. (For private schools): ________________________ Date Issued: _________________
CONTACT NUMBER: ______09057536734_________________________________ EMAIL: ______________
HOME ADDRESS: __Alegria, Sta. Monica Surigao del Norte______________________________
PURPOSE: ____Employment Abroad________________________________________

Employment Abroad Study Abroad

Seaman’s Book Others, pls. specify______________

____________________________________
APPLICANT/REPRESENTTIVE
(Signature over Printed Name)

CAV No._____________________
Claim Stub No. _______________ Date Release: / /

Documents to be submitted:

ORIGINAL and three (3) photocopies duly signed by the School Principal/Registrar of the following (For items 1,2, & 4):
1. Original copy of Diploma or
(For lost Diploma) Reconstructed Diploma
2. Original copy of Form 137 (Student’s Permanent Record)-Typewritten/computerized with complete entries
of grades from First Grading to Final Rating Period, First Year to Fourth Year and signed by the Principal
with date & purpose of issuance.
(If the school cannot issue Form 137-E/A due to fire incident) Certification from the school stating the
reason/s of failure to issue Form 137 & Certification from the Bureau of Fire Protection certifying the
incident happened in the school.
3. Special Order (4 certified photocopies/ For private school only)
4. Certificate of Graduation (state the complete date of graduation)
5. I.D. Picture (3 pcs. Passport Size with White Background)
6. Documentary Stamp (1 pc.@ P15.00)
7. Indorsement – CAV FORM 5
8. CAV 6 – TRANSMITTAL
9. SPA
10. 1 Photocopy of 1 valid card applicant & representative
For non-graduates:
1. Certification issued by the principal re: grade/year level completed by the pupil/Student
2. Form 137-E (For Elementary) or Form 137-A (For Secondary)
Note:
Form 137-E/A and Certification of Graduation/Certification of Year Level Completed must have been issued within 6
months prior to the application
CAV FORM 15- CAV APPLICATION FORM
Republic of the Philippines
DEPARTMENT OF EDUCATION
Caraga Region
Control Number: _____________________
Date of application: __________________
CAV APPLICATION FORM

NAME OF LEARNER: _________ LENIE__________DOMIṄOS____ ESCOBAL__

(First Name) (Middle Name) (Family Name)

DATE OF BIRTH: ____JULY 22, 1987________________________________________________

PLACE OF BIRTH: ___ALEGRIA, STA.MONICA SURIGAO DEL NORTE________________________

PRESENT ADDRESS: ____PHASE 1 LIBIS CANUMAY EAST VALENZUELA CITY___________________

CONTACT NUMBER: _____09057536734_________________________________________________

NAME OF SCHOOL: ______ BURGOS NATIONAL HIGH SCHOOL ____________________________

ADDRESS OF SCHOOL: _____ BURGOS NATIONAL HIGH SCHOOL ______________________

PURPOSE: (Please check any of the following)

EMPLOYMENT ABROAD FIANCE VISA

SEAMAN’S BOOKS/SRC TO TOURIST VISA

MIGRATION ABROAD REIMBURSEMENT OF EDUCATIONAL

ALLOWANCE/TUITION FEES OF CHILDEN OF OFW'S
SUCH OTHER PURPOSE AS MAYBE REQUIRED BY THE DFA

________________________________

APPLICANT/REPRESENTATIVE
(Signature over Printed Name)
(TO BE FILLED-UP BY THE REGIONAL OFFICE)
Requirements Graduates UNDERGRADUATES
Public Private Public Private
1. Student Permanent Records (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
b. Rating
c. Certificate from Division Office
8. Passport Size Picture (2pcs)*
9. Documentary Stamp

*If the application is not the learner himself/herself