Republic of the Philippines

Department of Education
Region VII, Central Visayas
DIVISION OF LAPU-LAPU CITY

APPLICATION FOR PERMIT TO STUDY

________________________
Date

DR. MARILYN S. ANDALES

Schools Division Superintendent
Division of Lapu-Lapu City

Dear Madam:

I, ________________________________ in compliance with Memorandum Circular No. 17, 1986, would like
to kindly request permission to study at ______________________________________ (Name and address of
school) effective ________________________ (Date of Class Opening).

Please find hereunder other details of this application:

Course: ____________________________ Major: _________________________

Subjects Completed:
Course Title Semester School Year Units
Number

Total Units Earned:

Subjects to be Taken:
Course Title Semester School Year Days of the Hours of Units
Number Week the Week

Total Units to be Taken:

A. CERTIFICATION

This is to CERTIFY that the course and subjects already completed and still to be taken by
Mr./Ms._________________________________as enumerated above are true and correct based on our
school records.

__________________________ ____________________
School Registrar/Dean Date Signed

B. APPLICANTS COMMITMENT

Should this application for permit to study be approved, I hereby commit to always give utmost priority to all
the activities, meetings and seminars of DepEd. I understand that I cannot use this as an excuse to be absent
or late from any activity, meeting or seminar that my School Head, District Head, Supervisor or any DepEd
Official will require. Should there be any violation of this commitment, I am mindful that there are certain
sanctions and consequences in accordance with the rules and regulations that may be imposed.

Name & Signature of Requesting Applicant : ____________________________________

Date Signed : ____________________________________

C. RECOMMENDATION OF THE SCHOOL HEAD

( ) Recommends approval
( ) Does not recommend approval
Due to:
_____ Low performance rating in the last school year
_____ Frequent lates and absences in the previous school year/s
_____ Observed health condition
_____ Assigned other administrative tasks in the school
_____ Others: __________________________________

His/her latest performance rating is: ______________________________

Describe his/her latest attendance records: _________________________

Other Remarks: ______________________________________________________

____________________________________________________________________

____________________________
Name & Signature of School Head

D. ACTION OF THE APPROVING AUTHORITY

As per recommendation of the School Head and upon evaluation of your application by this office, this
request for permission to study is hereby ( ) Approved / ( ) Denied, in accordance with the provisions
of Circular No. 17 series of 1980.

Other Remarks: ________________________________________________________________

MARILYN S. ANDALES, Ed. D. CESO VI

Schools Division Superintendent