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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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