Republic of the Philippines

Department of Education
REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS

PLANNING AND RESEARCH SECTION

REQUEST FORM
Learners Information System (LIS) Data Issues

***To be filled up by the requesting school.

DATE: ___October 14, 2020___

SCHOOL ID: ______307706_____
NAME OF SCHOOL: _________Lian National High School________
NAME: ______Jesusa Madlangsakay___________ SIGNATURE: ________________________
CONTACT NUMBER: ___09611827740______ E-MAIL ADD: jesusa.madlangsakay@deped.gov.ph
TYPE OF REQUEST:
LRN APPROVAL CORRECTION OF GRADE LEVEL
ENROLMENT OF INELIGIBLE CORRECTION OF LEARNER BASIC PROFILE
ENROLMENT WITH GAP TEMPORARY ENROLMENT

LEARNER’S DETAILS
LRN (if applicable): ___107410130380______
NAME: __________Pasno______ ________Icy Jenieses______ __________Galit________
(Last Name) (First Name) (Middle Name)
DATE OF BIRTH: _____January 9, 2003_____
GRADE LEVEL: _______Grade 10_______

***Required Documents
LRN Approval/Enrolment of Ineligible/with Gap
1. SF 9 / SF 10 / ECCD Checklist (incoming Grade 1)
2. Birth Certificate
Correction of Grade Level
1. SF 9 / SF 10 / ECCD Checklist (incoming Grade 1)
Correction of Learner Basic Profile
1. Birth Certificate
Temporary Enrolment
1. Affidavit of Undertaking

***To be filled up by the Planning and Research personnel.

Received by: __________________________________________ Date: ___________________

Documents Submitted: Complete With System Request: YES
Incomplete NO
Status of Request: For Approval Pending
For Disapproval No Action
REMARKS: ______________________________________________

Evaluated by: ___________________________________________ Date: ___________________

Approved by:____________________________________________ Date: ___________________

DEPEDBATS-PAR-F-023/R3/07-15-2020

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662
deped.batangas@deped.gov.ph
www.depedbatangas.org

CRN 44 100 18 93 0045

 Republic of the Philippines
Department of Education
REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS

DEPEDBATS-PAR-F-023/R3/07-15-2020

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662
deped.batangas@deped.gov.ph
www.depedbatangas.org

CRN 44 100 18 93 0045

 Republic of the Philippines
Department of Education
REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS

DEPEDBATS-PAR-F-023/R3/07-15-2020

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662
deped.batangas@deped.gov.ph
www.depedbatangas.org

CRN 44 100 18 93 0045

 Republic of the Philippines
Department of Education
REGION IV-A CALABARZON
SCHOOLS DIVISION OF BATANGAS

DEPEDBATS-PAR-F-023/R3/07-15-2020

Address: Provincial Sports Complex, Bolbok, 4200 Batangas City

(043)722-1840 / 722-1796 / 722-1437 / 722-2675 / 722-1662
deped.batangas@deped.gov.ph
www.depedbatangas.org

CRN 44 100 18 93 0045