Reference

1. Republic of the Philippines
Department of Education
CORDILLERA ADMINISTRATIVE REGION
SCHOOLS DIVISION OF APAYAO
Address: Provincial Government Center, Capagaypayan, Luna, Apayao, 3813
Email Address: apayao@deped.gov.ph
Website: http://www.depedapayao.ph
PERMIT TO STUDY
Name of Applicant: _____________________________ Position: ____________ Sex: ______
(Family Name, Given Name, Middle Name)
Employee No.: ___________ Contact Number: _____________ E-mail: ________________
Station Code: _________ Name of School/ Office: __________________________________
School/Office Address: __________________________________________________________
Subject/s & Grade/s level presently handled: ____________________________________
Name & Address of School where enrolled: _______________________________________
_________________________________________________________________________________
School Year: ______ Semester (Pls. check): 1st ___ 2nd ___ 3rd ___ Summer __________
(Course to be taken and schedule of classes: (COMPLETE the needed information based on registration/enrollment form
given)
Subject
Code
Subject Description Day/s of
the
week
Time No. of
Units
Note: Strict compliance of a maximum of nine (9) units to enroll every semester except for graduating students
(For Teachers).
Credit or Units Earned M.A. /
M.S.
Doctorate Others (Pls. specify):
_________________________
Total number of units earned:
Number of units to be earned
this Semester / Term
I declare under oath that I have personally accomplished this form which is a true,
correct and complete. I shall submit to the Administrative Unit, through channels,
certified true copy of the report of rating I shall obtain in the course during the semester
including the number of units earned.
_________________________ ____________________
(Signature of Applicant) Date

2. Address: Provincial Government Center, Capagaypayan, Luna, Apayao, 3813
Email Address: apayao@deped.gov.ph
Website: http://www.depedapayao.ph
CERTIFICATION
I, the undersigned, certify that the applicant is doing satisfactory work with an efficiency
rating of “Very Satisfactory” (3.500 – 4.499) or higher, that I shall recommend the
revocation of this permission if the application violates any or all regulations given in
Circular No. 17, s. 1960.
_______________________________________________________
Signature Over Printed Name of School Head/Division Chief/ASDS
APPROVED:
Subject
Code
Subject Description Day/s of
the
week
Time No. of
Units
Recommending Approval: Approved:
JERRY B. SARIO, JR. IRENE S. ANGWAY PhD, CESO V
Officer In-Charge Schools Division Superintendent
Assistant Schools Division Superintendent
For Administrative Unit Staff Only
Permit No.
_______________
Expiry on: 1st ___ 2nd ___ 3rd __
Summer _____________
School Year: ________________
Recorded by: Date: