SDO ALIAGA

ANNEX
LA PURISIMA ELEMENTARY SCHOOL
Teachers’ Clearance
School Year 2021-2022
The Principal
Sir/Madam:
This is to inform you that I have satisfactorily settled all the property and financial obligations in the school and
that I have submitted all the required reports as listed below. May I then be granted the Clearance for School Year 2021-
2022
CHECKED BY:/Date
(Signature over printed name) CHECKED BY:/Date
(Signature over printed name)
1. School Form 1: School Register ____________
5. Classroom inventory and room safety
2. School Form 2: Daily Attendance
a. room keys __________________
of Learners ____________________
b. books __________________
3. Grading Sheets ____________________
c. equipment ___________________
4. School Form 5: (Report on
d. furniture ___________________
Promotion & Level of Proficiency ______________
6. X-ray & Urine, ECG Exam __________________
12. DepEd Form 137 ____________________
7. Dental Result __________________
13. DepEd Form 138 ____________________ 8. Financial Obligations
14. Return of Unissued Cards ____________________ Teachers Club Dues ____________________
15. CS Form 48 ____________________ Canteen Funds ____________________
16. Guidance Form ____________________
17. Updated Form 212 (PDS) ____________________ 9. Performance Rating ____________________
18. Weekly Home Learning Plan _________________
10. SALN as of December 2021 __________________
19. Test Notebook _______N/A_______-__
20. Nutritional Status 11. Latest Instructional Materials Prepared__________
(Feeding teacher) ____________________
21. Class Organizational list
(Gr. /Yr. level chairmen) ____________________
22. List of Retained/
Drop-Out/ Transferred In and Out/
Failures ____________________
23. List of Students with
General Average ____________________
24. Income Tax Return (ITR) ____________________
25. Library

In the exigency of service, I am willing to give my helping hand for whatever is needed.

Present Home Address: Sitio Osmena, Brgy. Dulong Bayan, Quezon Nueva Ecija
Telephone/Cell phone Numbers:0956-359-9051/0909-066-6347

RACHELLE G. BISA
Recommending Approval: Teacher I

ROSITA D. MALLARI
School Property Custodian
Date: __________________ Approved and clearance granted:

ELIZABETH S. TRINIDAD
School Treasurer
Date: __________________
ROGEL R. ROBLES
Head Teacher I
Date: ______________