Republic of the Philippines

Department of Education
REGION II – CAGAYAN VALLEY
SCHOOLS DIVISION OF ISABELA

LEARNER INFORMATION (LIS) CHANGE REQUEST

AND ISSUANCE OF LEARNER RERFENCE NUMBER (LRN) FORM

Control Number: _____________________ Date: ___________________

CLIENT INFORMATION
Name: ____________________________________
Position/Designation: ______________________
School ID: ______________________________
School Name: _______________________________
Contact Number: ___________________________
E-mail Address: ____________________________
LRN: _____________________________________
Name of Learner:
____________________________________________
Grade and Section: _________________________
CHANGE REQUEST
Enrolment with Gap
Reason/s for the gap (please specify)
____________________________________________
____________________________________________
Enrolment of Ineligible
Erroneously tagged EOSY/No Status
Correct Status: ____________________________
Reason for the correction: ____________________
____________________________________________
____________________________________________

ISSUANCE OF NEW LRN Others (please specify)

Reasons for not having LRN
1. From accredited/recognized school
School Year last attended: ______________
School last attended: ___________________
_______________________________________
2. Undergone catch-up program and assessed
school readiness
Result of the assessment: ________________
_________________________________________
3. From not accredited local school
Certification/Accreditation/Equivalency Exam:
a. PEPT Certificate No. ________________
b. PVT Certificate No. __________________
4. From foreign/Philippine school abroad
Last School Year attended: ___________________
Last School attended: ________________________
_____________________________________________
5. From ALS
Certification/Accreditation/Equivalency Exam:
a. PEPT Certificate No. ________________
b. PVT Certificate No. __________________
6. Others (please specify) ________________________
_____________________________________________
____________________________________________
____________________________________________
____________________________________________
SUBMITTED BY
______________________________
Client’s Printed Name and Signature
(For Planning Officer’s Use Only)
Approved Disapproved
REMARKS/ACTION TAKEN:
____________________________________________
____________________________________________
Date Acted: ________________________________
Received/Acted by:
TIMOTEO H. BAHIWAL
Planning Officer III

Alibagu, City of Ilagan, Isabela 3300 https://deped-isabela.com.ph

(078) 323-0281 (078) 323-2015 Sdo Isabela
isabela@deped.gov.ph
Doc Code: FM-SGO-PLA-001 Rev: 00
As of: July 02, 2018 Page: 1