Republic of the Philippines

DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
TOBOR NATIONAL HIGH SCHOOL

Control No.:_____________

Date of Application: ______________________

Date of Release: _________________________

School Name: TOBOR NATIONAL HIGH SCHOOL

School ID: 300262

REQUEST FORM FOR ACADEMIC SCHOOL RECORDS

Name of Learner: ______________________________________________________________

Date & Place of Birth: ___________________________________________________________

School Year Last Attended / Graduated: ____________________________________________

Present Address: _______________________________________________________________

Contact No.: __________________________________________________________________

PURPOSE: (Please check any of the following)

EMPLOYMENT ABROAD FIANCE VISA STUDENT VISA

SEAMAN’S BOOK/SRC TOURIST VISA DESCENDANT’S VISA

MIGRATION ABROAD REIMBURSEMENT OF

EDUCATIONAL
ALLOWANCE /TUITION
FEES OF CHILDREN OF
OFW’S

SUCH OTHER PURPOSE AS MAYBE REQUIRED BY THE DFA

_______________________________________________
Signature Over Printed Name
(Applicant/Representative)
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
TOBOR NATIONAL HIGH SCHOOL

CERTIFICATION OF GRADUATION

TO WHOM IT MAY CONCERN:

This is to certify that, based on available records in this school, the following information pertaining

to NENITA EUGENIO MACUGAY with Learner Reference Number ( __N/A__ ) appear satisfactorily graduated

from Secondary Course for the School Year 2006-2007 as prescribed by the Department of Education.

This certification is issued on March 29, 2019 upon the request of NENITA EUGENIO MACUGAY in

connection with his application for Certification, Authentication and Verification.

JANUS B. SALINAS, Ph.D.

Head Teacher I
OIC, Office of the School Head
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
TOBOR NATIONAL HIGH SCHOOL

1st Indorsement
March 29, 2019

Respectfully forwarded to the Regional Director, Deped Regional Office I, San Fernando City,
La Union, the herein request of NENITA EUGENIO MACUGAY 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.

JANUS B. SALINAS, Ph.D.

Head Teacher I
OIC, Office of the School Head
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region I
Schools Division Office I Pangasinan
TOBOR NATIONAL HIGH SCHOOL

CERTIFICATION

TO WHOM IT MAY CONCERN:

This is to certify that NENITA EUGENIO MACUGAY with Learner Reference Number ( N/A__)
has satisfactorily completed/graduated from Secondary Course as prescribed by the Department of
Education, with the following particulars:

1. Name of School: TOBOR NATIONAL HIGH SCHOOL

2. School Address: Barangay Tobor, Malasiqui, Pangasinan

3. Grade Level completed: ____________ School Year Completed: _________

4. Graduated on: Grade 10 (Fourth Year) School Year Completed: 2006-2007

5. Special Order: ____________________ Date: ________________________

This is to certify further that English Language was used as the medium of instruction in all
subjects taught in the above-mentioned school, except for subjects that require the use of Filipino
language only.

This certification is issued on March 29, 2019 upon the request of NENITA EUGENIO
MACUGAY in connection with his application for Certification, Authentication and Verification.

JANUS B. SALINAS, Ph.D.

Head Teacher I
OIC, Office of the School Head