Education Service Contracting

Application Form
ESC Form 1

ABOUT ME
Learner Reference Number (LRN)

Last Name: OMPAD

First Name : NIÑA MARIE

Middle Name : LANDERAS 2x2 ID Photo

Suffix (i.e. Jr., III) Date of Birth: JULY 01,2008

Place of Birth: CEBU CITY MEDICAL

CENTER

Nationality Gender
☐Filipino ☐Others (Specify) ☐Male ☐Female

ADDRESS AND CONTACT DETAILS

Street Address :blk.7lot 51 Magsaysay st.
pasil CEBU CITY Barangay/District SUBA,7

Municipality/City CEBU CITY Province CEBU

Zip Code Mobile/Landline No. Email Address

ninamarie.3
3.@gmail.co
6000 2325931 m
ABOUT MY FAMILY
First Name Middle Name Last Name Relationship

1. Mary Carolyn Amaba Ompad Mother

2. Ramell Aparilla Lazaderas Father
P

3. Limar Ompad Brother

3. Doris Avila Ompad Guardian
5.

6.

Total No. of Siblings

Note: Use back page if more than six family members

Does your family own any of the Motorcycle/Pedicab Car, Van, Pick-up or Truck Land or Farm
following ☐Yes ☐No ☐Yes ☐No ☐Yes ☐No

☐Company Provided/Living with No of Bedrooms

Home details ☐Owned ☐Rented Relatives
 SUPPORT FOR COST OF SCHOOLING
Last Name First Name Sources of Income Gross Monthly Income

OMPAD RAMELL ☐ Locally Employed ☐ Php 0-5,000

☐ Employed Abroad
☐ Php 5,001-10,000
☐ Self-employed-
☐ Php 10,001-15,000
Professional
Father ☐ Php 15,001-20,000

☐ Self-employed-
☐ Php 20,001-25,000

Business

☐ Php 25,001-50,000

☐ Retired/Unemployed

☐ More than Php50,000

☐ Others: __________
 ☐ Locally Employed
☐ Php 0-5,000
☐ Employed Abroad
☐ Php 5,001-10,000
☐ Self-employed-
☐ Php 10,001-15,000

Mother
NOVIE OMPAD Professional
☐ Php 15,001-20,000
☐ Self-employed-
☐ Php 20,001-25,000
Business
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ More than Php50,000
☐ Others:___________
☐ Locally Employed
☐ Php 0-5,000
☐ Employed Abroad
☐ Php 5,001-10,000
DORIS OMPAD ☐ Self-employed-
☐ Php 10,001-15,000
Professional
Guardian ☐ Php 15,001-20,000
☐ Self-employed-
☐ Php 20,001-25,000
Business
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ Others: ☐ More than Php50,000
housewife__________
☐ Locally Employed
☐ Php 0-5,000
☐ Employed Abroad
☐ Php 5,001-10,000
☐ Self-employed-
Person Helping Send ☐ Php 10,001-15,000
Professional
the Child to School ☐ Php 15,001-20,000
☐ Self-employed-
(If applicable) ☐ Php 20,001-25,000
Business
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ More than Php50,000
☐ Others:___________
*For employees, it refers to the gross monthly salaries and wages before taxes and other deductions. It includes basic pay,
overtime pay, commissions, tips, allowances and one-twelfth of annual bonuses. For all others, it refers to the average monthly
earnings from their business, trade, profession, investments and/or pensions.
ABOUT MY ELEMENTARY SCHOOL
Name of Elementary School pasil School Type ☐Public ☐Private
elementary school

Province City/Municipality Barangay/District

If the Elementary School is Private, please indicate the school fees charged by the Elementary School.

Level Tuition (Php) Other (Php) Miscellaneous (Php)

Grade 6

ATTESTATION
Recent Identical 2x2 ID photo (2 copies)
PSA Certified Birth Certificate
Photocopy of Grade 6 Report Card
Documents attached to this application Latest Income Tax Return for the previous year or Certificate of Tax
Exemption or Municipal Certification of Unemployment of Parents/Legal
Guardian
I certify that my answers are true and correct to the best of my knowledge.

I am aware that the information supplied in this form will be retained by PEAC on a database and will be processed in
compliance with the Data Protection Act of 2012.

I consent that the information herein may be used for reports both internally and to the Department of Education.
Signature of Student over printed name Date

Ninia ompad 9/4/2020

Signature of Parent/Guardian over printed name Date

Doris ompad 9/4/2020