EXTENSION LOAD CREDIT (ELC) TERM

APPLICATION FORM SEM AY XXXX-XXXX

PERSONNEL INFORMATION
Name Sex
Last Name, First Name, M.I.
c Female c Male

College/ Unit Department Faculty Position Nature of Appointment

LOAD CREDIT INFORMATION

ELC Unit Particulars Total ELC Unit/s Requested Remarks
Project/ Activity/ Output
Role
No. of Hours/ Days
No. of Beneficiaries
Percentage of beneficiaries who rate the
training course/s and advisory services
as satisfactory or higher in terms of
quality and relevance

SDGs Addressed
Citation Recognition Received
Title
Conferring Agency or Body
Year Received
TOTAL

EXTENSION WORK INFORMATION

Objectives Keywords Type of Beneficiaries

Name of Beneficiaries

Location Start Date Expected End Date Actual/Exension End Date

Budget Funding Agency Name of Partner Agency/ies

Subject Area of Interest

Staff Involved (Use form ##)

Major Equipment Procured (Use form ##)
Supporting Documents (Use form ##)

I certify that all information/data in this form are true and correct to the best of my knowledge. I understand that a report or proof of output is to be submitted to
OVCRD thru OEC at the end of the semester or term for which ELC is granted and at the end of the project period. I further certify that I have no overdu
accountabilities for OECS-funded and managed projects.

Applicant's Signature Date

RECOMMENDATION ELC TOTAL UNIT/S RECOMMENDED

We certify that we have reviewed this ELC application and that the requested load credit/s was were pre-assigned based on the
College/Unit's approved Extension Work Agenda for the Academic Year. We further certify that this application complies with the College/
Unit's detailed guidelines for extension work and were evaluated by the College Executive Board or equivalent body.

Signature over Printed Name of Dept. Chair Signature over Printed Name of College/ Unit Director
Date: Date:

ENDORSEMENT/ APPROVAL ELC UNIT/S APPROVED

OECS Director Vice Chancellor for Academic Affairs

/ Unit Director